<p> EOL Scholarship-Learning Chinese through Tutoring (LCT) Application Form</p><p>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</p><p>SECTION 1: Personal Information</p><p>Full-name Dr./Mr./Ms./Mrs. First Name/Given Name Middle Name(s) Family Name/Surname Address for correspondence: Street address </p><p>City State/Province Postal Code Country</p><p>Telephone</p><p>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:</p><p>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 </p><p>SECTION 2: Education Background</p><p>1 College/University: </p><p>Major: </p><p>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</p><p>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: </p><p>SECTION 5: Personal interests, including achievements and motivation Tell us about your interest to China. Attached (300 words max)</p><p>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</p><p>Signature: Name in Print Date:</p><p>2</p>