KSU CLC Application

崑山科技大學國際學院華語中心入學申請表
Kun Shan University Chinese Language Center Application Form

請以中文或英文整齊書寫或打字，否則不予受理。
Please TYPE or PRINT in clear Chinese or English. Documents that are not clear will not be considered.
1. 欲申請就讀期別 Please mark the term you would like to begin your studies.
□春季班 Spring - 15 hours/week □夏季班 Summer - 15 hours/week
□秋季班 Autumn - 15 hours/week □冬季班 Winter - 15 hours/week
2. 個人資料填寫 Personal information
英文姓名 Last___elmi_ First ____khalid________ Middle___has
san____
English Nam 須與護照相同 Must be the same as shown in your PASSPORT
e
中文姓名
______________________________________
Chinese Nam 如果你希望由我們為您取中文姓名，請在填寫「華語中心取名」貼 2 吋照片
If you want the Chinese Language Center to give you a Chinese n Attach Recent
e ame, please copy the following sentence into the answer of "Nam 2-inch Photo Here
e in Chinese": 「`由華語中心取名」
國籍
Nationality 須與護照相同 Must be the same as shown in your PASSPORT
生日性別
10/04 / 1995 □男 Male
Date of Birth male □女 Female
電話護照號碼
Phone No: Passport Number
最高學歷 ☐ 高中 Senior High School
Highest Leve 護照有效期限
☐ 大學 University
MM / DD / YY
l of Educatio Date of Expiration
☐ 研究所 Post-graduate
n
電子信箱
______________________________________
E-mail 學生繳費、開課...等重要通知，均以電子郵件寄發，請務必提供有效之電子郵件帳號。Please enter your(applicant's) personal email a
ddress to stay in touch and keep up-to-date with all our latest news.
通訊地址 Addr
_____________________________________________
ess 入學許可會寄到這個地址，請務必以英文或中文詳細正確填寫。
The admission letter will be mailed to this address. Please print clearly inEnglish or Chinese.
是否需要辦理中文研習簽證?
☐ 否 No ☐ 是 Yes
Do your need to apply Visitor Vi
(依據中華民國政府之規定，須持有中文研習簽證或居留證之外國學生，每週必須上課 15 小時。 According to
Ministry of Education regulations, students applying for the visa of
sa? studying Chinese or the ARC, must take 15 hours a week.)
3. 在本校研習之經費來源 Major source of financial support during the studies at our school?
☐ 個人儲蓄 Personal Savings ☐ 家人支援 Family Support
☐ 獎學金 Scholarship (☐台灣獎學金 Taiwan Scholarship ☐ 其他 Others: )
☐ 其他 Others:
4. 進修目的或學習計畫 Statement of purpose / Study Plan?
_______________________________________________________________________
_________________________________________________________________________
5. 中文能力 Chinese Proficiency

你學過中文嗎？ Have you ever learnt Chinese?
☐ 學過 Yes ☐ 沒學過 No (以下免填，Please pass the questios blow.)
你學過哪些教材？ What Chinese study materials have you used?
1.
2.
3.
4.
學習中文多久？ ☐ 0-1 year ☐ 1-2 years
How long have you learnt Chinese? ☐ 2-3 years ☐ 3 years~
您是否參加過任何中文能力檢定？☐是 Yes，請回答下列問題 ☐否 No
Have you ever taken a Chinese Proficiency Test? ( If yes, please answer the following qu
estions.)
☐TOCFL(TOP-Huayu) 證書 Certificate______________；MM / DD / YY
☐漢語水平考試(HSK) 證書 Certificate______________；MM / DD / YY
☐其他 Other 證書 Certificate______________；MM / DD / YY
你覺得你現在的中文能力怎麼樣？How do you think of your Chinese ability?
聽 Listening ☐精通 Excellent ☐佳 Good ☐尚可 Average ☐差 Poor
說 Speaking ☐精通 Excellent ☐佳 Good ☐尚可 Average ☐差 Poor
讀 Reading ☐精通 Excellent ☐佳 Good ☐尚可 Average ☐差 Poor
寫 Writing ☐精通 Excellent ☐佳 Good ☐尚可 Average ☐差 Poor
6. 緊急聯絡人 Emergency Contact Information
姓名 Name 電話 Phone No.
關係 Relationship 地址 Address
7. 在台緊急聯絡人 Emergency Contact Information in Taiwan

姓名 Name 電話 Phone No.
關係 Relationship 地址 Address
8. 醫療保險調查 Survey on Medical Insurance
☐已有居留證並加入全民健康保險 I hold an ARC and have joined National Health Insurance.
☐已自行投保海外醫療保險 I have overseas medical insurance.
☐我沒有任何保險。I do not have any insurance.
9. 是否需申請宿舍 Do you wish to apply for a dorm：□是 Yes □否 No
☐我要住宿舍 2 人房 apply for dorm 2-shared room.
☐我要住宿舍 3 人房 apply for dorm 3-shared room.
10. 申請所需表件如下；請務必備齊文件，方受理申請 APPLICATION MATERIALS must include-
☐護照影本 Photocopy of the first page of the passport
☐二吋半身正面照片 2 張 2 2-inches Photographs
11. 學費退費規定 Refund related regulations ☐勾選確認 check to confirm
★若因人數不足未能開班時，已繳學費無息退還；若因無法取得簽證入境者，已繳學費無息退還。
開課前學生若因個人因素無法上課，已繳學費不予退還，亦不可轉讓，但可順延一期上課。
開課後學生若因個人因素無法上課，或中途缺課者，已繳學費不予退還，並不得順延一期上課。
In case of no classes due to insufficient number of students, the tuition fees paid will
be refunded.
If you are unable to obtain a visa entry, the tuition fees paid will also be refunded.
If one is unable to attend classes due to personal factors before the start of the cours
e, the tuition fees paid will not be refunded and is not transferable, but one can resu
me class for a grace period of one semester.
After the start of the course, if one is unable to attend classes due to personal factor
s, or if one is absent from the class during the course, the tuition fees paid will not be
refunded, and the class will not be postponed.
12.個人資料保護法聲明 Statement of Personal Information Protection Act ☐勾選確認 check to c
onfirm
本人同意及授權崑山科技大學華語中心所蒐集之個人資訊僅作為華語中心之課務、活動及相關行政業務之使用，亦了解該中心將依個人資料保護法之相關規定妥善
管理，未經本人同意，絕不任意對其他第三者揭露。
I hereby consent and authorize Chinese Language Center (CLC) of Kun Shan Universi
ty of Languages to collect the personal information that I provide for the purpose of a
ffairs of course, activities and administrative work in CLC. I also understand that CLC
will not disclosed this information to third parties without my agreement.
我已了解崑山科技大學華語中心之華語正規班相關規定，並同意遵守。
I have completely understood all the information indicated by Kun Shan Chinese Langu
age Center, and I agree, I will follow the regulations without transgression.
申請人簽名 Applicant Signature 日期 Date：

請寄至: 71070 台南市永康區崑大路 195 號崑山科技大學華語中心收或 lcc@mail.ksu.edu.tw
Mail to Chinese Language Center, Kun Shan University No.195 Section 2, No.195, Kunda R
d., Yongkang Dist., Tainan City 710, Taiwan (R.O.C.) or lcc@mail.ksu.edu.tw
崑山科技大學華語中心 71070 台南市永康區崑大路 195 號

Chinese Language Center, Kun Shan University No.195 Section 2, No.195, Ku
nda Rd., Yongkang Dist., Tainan City 710, Taiwan (R.O.C.)
TEL: 886-6-2727175 TEL:886-6-2050006
E-mail:lcc@mail.ksu.eud.tw

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崑山科技大學國際學院華語中心入學申請表

Kun Shan University Chinese Language Center Application Form

☐ 獎學金 Scholarship (☐台灣獎學金 Taiwan Scholarship ☐ 其他 Others: )

4. 進修目的或學習計畫 Statement of purpose / Study Plan?

5. 中文能力 Chinese Proficiency

How long have you learnt Chinese? ☐ 2-3 years ☐ 3 years~

姓名 Name 電話 Phone No.

7. 在台緊急聯絡人 Emergency Contact Information in Taiwan

申請人簽名 Applicant Signature 日期 Date：

崑山科技大學華語中心 71070 台南市永康區崑大路 195 號

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