<p> Chung Hua University APPLICATION FORM</p><p>(Plea se complete in block letters) Personal Details:</p><p>Title: ______Surname/Family Name:______First Name: </p><p>______Date of Birth: Day Month Year______Male/Female: ____ Native Language: ______Nationality: ______Country of Permanent Residence: ______Passport Number: ______Contact Details: Address for Correspondence:______Permanent Address (if different from above ):______Telephone Number:______Fax Number:______Country Code/Area Code/Phone Country Code/Area Code/Phone</p><p>Email: ______Emergency Contact: Name:______Relationship:______</p><p>Telephone Number: ______Study Details:</p><p>Your Proposed Date of Entry: Month: ______Year: ______Study Program: □ Ph.D. □ Master □ Bachelor □ Mandarin</p><p>Research Interest:______</p><p>Department/ College:______</p><p>Educational History: Dates Attended Name of Institution Grades Achieved Degree and Subject </p><p>1 AF0-4-001A</p><p>Working Experience: Dates Post Name of Organization Duties</p><p>Are you physically sound and well? (□ Yes or □ No). If not, please describe your status with respect to any disability:______</p><p>Financial Statement: Please describe how your fees and expenses will be financed.</p><p>References (for graduate programs only): Referee 1: Title:______Name:______Address:______TEL: ______Fax: ______Email: ______</p><p>Referee 2: Title:______Name:______Address:______</p><p>2 AF0-4-001A ______TEL: ______Fax: ______Email: ______</p><p>Supporting Documents: Transcript of Qualification: □ Enclosed □ To Be Followed Financial Statement: □ Enclosed □ To Be Followed Two Reference Letters: □ Enclosed □ To Be Followed Study Plan: □ Enclosed □ To Be Followed Health Certificate: □ Enclosed □ To Be Followed</p><p>I declare that the information on this form is true and agree to abide by all of the University’s regulations if registering as a Chung Hua student.</p><p>Applicant’s Signature: ______Date: ______</p><p>For More Information: The Office of International Programs, Chung Hua University, No. 707, Sec.2, Wu Fu Rd., Hsin Chu Taiwan 30012 TEL: 886-3-5186176, FAX: 886-3-5186174 www.chu.edu.tw ; email: international @chu.edu.tw </p><p>Office Use Only: Department / College:</p><p>REMARKS</p><p>Qualifications: </p><p>1. Applicants must be a graduate or an undergraduate from accredited universities, colleges or senior high schools; 2. If the applicants carry both Overseas Chinese Students and foreign nationality </p><p>3 AF0-4-001A status, the applicants must make a choice between them. The admission will be revoked immediately if they are found to have applied according to both statuses. </p><p>Required Documents (Please make sure all are ready before submitting):</p><p>1. □ A completed Application Form. 2. □ One copy of the Passport. 3. □ Financial Statement: issued by scholarship documents or a bank statement, showing the applicant is able to cover all the expenses needed when attending the program. 4. □ Four Photos (1〞* 1.5〞). 5. □ A report of the Health Certificate (including HIV and lung X-ray test). 6. □ One copy of the highest Educational Diploma with notarized English translation. The Diploma has to be authenticated by the local Taiwan Representative Office. (for degree programs only). 7. □ One copy of the Academic Records with notarized English translation. The Records has to be authenticated by the local Taiwan Representative Office. (for degree programs only) 8. □ A Study Plan (for degree programs only). 9. □ Two Reference Letters (for graduate programs only).</p><p>4 AF0-4-001A</p>