EOL Scholarship-Learning Chinese Through Tutoring (LCT)

EOL Scholarship-Learning Chinese through Tutoring (LCT) Application Form

INSTRUCTIONS: Please complete this form, following the instructions carefully. Provide the complete form, requested attachments, and a recent photograph (head shot) in.jpg format to me at [email protected] The deadline for submitting applications is： Feb.15 2016 for Fall semester 2016

SECTION 1: Personal Information

Full-name Dr./Mr./Ms./Mrs. First Name/Given Name Middle Name(s) Family Name/Surname Address for correspondence: Street address

City State/Province Postal Code Country

Telephone

Country Code City Code Number Country Code City Code Number BUSINESS 口 HOME 口 Date of birth Cell Phone number: Emergency contact person and contact number:

Email: Nationality: Citizenship: Native English Speaker： yes（） no（） Chinese level：beginning（）mid-level（） advanced ( ) if you took HSK, please provide score ( ) Do you have TEFL/TESOL certificate 口 Yes 口 No

SECTION 2: Education Background

1 College/University:

Major:

SECTION 3: Community and professional engagement Please provide information about your participation in clubs at university, community groups, professional organizations and other voluntary activities outside your college study: Organization Your role Dates Activities/accomplishments

SECTION 4: Exposure outside of the Country Study, travel or residence outside of the Country for last three years: Duration, date and location: Duration, date and location: Duration, date and location:

SECTION 5: Personal interests, including achievements and motivation Tell us about your interest to China. Attached (300 words max)

I DECLARE THAT ABOVE IMFORMATION IS TURE, I PROMISE THAT I DO NOT HAVE CRIMINAL RECORDS AND HEALTHY ENOUGH TO PERFORM THE DUTY REQUIRED BY THE LCT PROGRAM

Signature: Name in Print Date: