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2. PRESENT EMPLOYMENT

1. Designation

Month year

Since

2.Institute / Organization

3.Type of Business

4.Address

Tel:

Fax:

5.Type of the Organization

□Govt. Ministry / Agency □University / Institution

□Govt. / State Owned Enterprise □Locally Owned Enterprise

□Joint Venture □Foreign Owned Enterprise

□NGO

6.Present Job Duties

3. PREVIOUS WORKING EXPERIENCE Note:For Each Pervious Job Experience

Designation

Organization

Period Of Employment

Job Duties

1.

2.

3.

4. EDUCATION AND TRAINING Note:Highest Diploma Only

School Name

Subject

Qualifications

(Certificate / Diploma / Degree)

Year Obtained

1.

2.

5. RECOMMENDATION OF AUTHORITY

Comments on educational qualifications, experience in the training subject, age, and personality of the candidate:

Responsible official: Title _____________________ Signature:_____________________

Name ____________________ Date:_________________________

6.DECLARATION BY CANDIDATE

1. I hereby declare that the information as provided by me in this document is true and accurate. I understand and accept that any false declaration of information on my part will disqualify me from the program, even when it is in progress.

2. I declare that I am not suffering from any serious or chronic disease and that I am not hindered in the performance of my duties by any illness or disability:

3. I hereby undertake to abide by the laws of the Republic of China during my stay in Taiwan and undertake to do the following:

    1. Fulfill due performance as required in attendance.

    2. Not seek employment or engage in any political activities.

    3. Bear any additional expenses or risks incurred as a result of any changes initiated by myself.

    4. Not bring with me any family members or friends.

4. I fully agree that the TaiwanICDF has the right to terminate the scholarship if, during my stay in Taiwan, my behavior causes any difficulties for the management of the TaiwanICDF or the training institution.

5. I understand that during my stay in Taiwan, only those matters related to the training program will be settled in accordance with the CAEDF-Taiwanese / NPUST’s rules and regulations, and that the CAEDF-Taiwanese / NPUST’s decision will be final and will be implemented accordingly. Cases irrelevant to the training program shall be otherwise of my own responsibilities and at my own cost.

Signature:_______________________

Date:___________________ Name:_______________________


7. APPLICATION FOR ADMISSION

To the Applicant: Please complete the form with legible prints. If necessary, additional pages of the same size may be attached.

1. Full Name

2. Nationality

3. Major subject planned to study at the NPUST

4. Extra-curricular activities

5. Publications

6. Attach an autobiography

7. Attach a research or study plan

8. Attach three recommendation letters

Applicant’s signature

Date of Application

8. STUDY PLAN

To the Applicant: The study plan should content the following items in details. Please use additional pages of the same size to attach the context.

1. Title

2. Introduction

3. Objective

4. Action plans

5. Anticipated results

6. References

Applying for: National Pingtung University of Science and Technology (NPUST)

Undergraduate Program in Tropical Agriculture

INSTRUCTION:

PART 1: Personal Details and Health Declaration - to be completed by the applicant

I hereby certify that the following information is true and complete, and agree that any misrepresentation or deliberate omission of a material fact on this form may result in the withdrawal of an offer of a place or scholarship, or may result in the termination of any such offer at a future date. I hereby grant the TaiwanICDF permission to share information contained in my Medical Examination Form with relevant authorities.

X

  Signature Date

PART 2: Medical Examination - to be completed by certified physician

National Pingtung University of Science and Technology (NPUST) reserves the right to require the applicant to undergo a future medical examination after he/she arrives in the Republic of China (Taiwan).

P

PHOTO

ART 1: HEALTH DECLARATION

Nationality:

Name: (Last)

(First)

(M. Initial)

Gender: MaleFemaleDate of Birth: Y/ M/ D/

Health History:
Have you ever suffered any of the following conditions? Please mark X in appropriate box

Psychiatric illness

Epilepsy

Migraine

Asthma

Tuberculosis (PTB)

Hypertension (HPT)

Diabetes Mellitus (DM)

Heart Diseases

Malaria

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

Thyroid Diseases

Kidney Diseases

Cancer

HIV/AIDS

Venereal Diseases

Leukemia

Hemophilia

Hepatitis

Measles

German Measles (rubella)

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

□   □

Please State (if any)

Other illnesses

……………………………………………………………………………………………………….

Operation / Surgical

……………………………………………………………………………………………………….

Allergic to

……………………………………………………………………………………………………….

Family Medical History (if any)

Father:…………………………………………… Mother: ……………………………………………

Past Year Life: Please select

1. Sleep: □7~8 hours every day □Under 7~ 8 hours □Often suffer from insomnia

2. If that is basic to exercise each time for 30 minutes and 3 times every week at least, did you achieve? □No □Yes

4. Do you often feel anxious and worried? □Few or not □Sometimes □Often

5. Do you often feel the chest is stuffy? □No □Sometimes □Yes

6. Stomach-ache? □No □Sometimes □Often;. Headache? □No □Sometimes □Often

7. The menarche (girl only): (1) The age of the menarche: ______years-old

(2) Is menstrual cycle regular? □No □Yes(Date of partition ______day)

(3) Do you ever have menstrual cramp phenomenon □No □Yes

PART 2: MEDICAL EXAMINATION

Physician must complete all questions and give additional comment where necessary. Kindly note that physician is responsible for the information, suggestions and recommendation regarding the applicant’s health given in this form.

Certified original lab data need to be attached as reference.



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