1、修平技術學院外國學生入學申請表Hsiuping Institute of TechnologyInternational Students Application for Admission Form請以中文或英文正楷詳細逐項填寫本入學申請表一式兩份Please type or print legibly this application form in Chinese or in English with two copies.請郵寄填寫完整的入學申請表及其他相關資料至：修平技術學院研究發展處中華民國台灣 41280 台 中 縣 大 里 市 工 業 路 11 號Please mail you
2、r complete application form and other materials to:Hsiuping Institute of Technology, Office of Research and DevelopmentNo.11, Gongye Rd., Dali City, Taichung County 41280, Taiwan, R.O.C.請 貼 上 近 半 年2 吋 照 片Attach 2” photowithin half a year基本資料Personal Information編號No.中文姓名Chinese Name： 護照號碼Passport No.
3、：_英文姓名English Name： Last First Middle出生日期Date of Birth (mm/dd/yy)：_ 性別Gende r：男性 Male 女性 Female出生國家Country of Birth：_ 國籍Nationality：_永久住址Permanent Address：_通訊地址Mailing Address：_住家電話Home Phone No.：_ 電子信箱E-mail：_法定監護人Legal Guardian中文姓名Chinese Name： 英文姓名English Name： 住址Address： 住家電話Home Phone No.：_ 關係S
4、pecify Relationship： 如有疾病或缺陷，請敘明之 If you have any illness or handicap, please specify： 教育背景Education Background申請資料Application Information攻讀學位Intended Degree： 學士（四年制）Bachelor Degree (4-year) 學士（二年制）Bachelor Degree (2-year) 碩士 Master Degree申請科系Which department or graduate institute do you expect to s
5、tudy at Hsiuping Institute of Technology?工程學群School of Engineering機械工程系 Dept. of Mechanical Engineering 電機工程系 Dept. of Electrical Engineering電子工程系 Dept. of Electronic Engineering 工業工程與管理系 Dept. of Industrial Engineering & Magt.化學工程系 Dept. of Chemical Engineering管理學群 School of Management財務金融系 Dept. o
6、f Financial Magt. 國際企業經營系 Dept. of International Business Magt.人力資源發展系 Dept. of Human Resource Development行銷與流通管理系 Dept. of Marketing & Distribution Magt.資訊學群 School of Informatics資訊管理系 Dept. of Information Management 資訊網路技術系 Dept. of Information Network Technology數位媒體設計系 Dept. of Digital Media Desi
7、gn語文學群 School of Languages應用英語系 Dept. of Applied English 應用中文系 Dept. of Applied Chinese應用日語系 Dept. of Applied Japanese研修費用來源Means of Financial Support個人儲蓄 Personal Savings 父母供給 Parental Support獎助學金 Scholarships 其他（請說明）Other (Please Specify)：_是否申請本校所提供之助學金? Will you apply scholarship offered by Hsiup
8、ing Institute of Technology? 是 Yes 否No中文程度 How do you evaluate your Chinese language proficiency? 聽 Listening 優 Excellent 佳 Good 可 Fair 差 Poor 說 Speaking 優 Excellent 佳 Good 可 Fair 差 Poor 讀 Reading 優 Excellent 佳 Good 可 Fair 差 Poor 寫 Writing 優 Excellent 佳 Good 可 Fair 差 Poor請詳列您曾經唸過的大學、學院及（或）中學，從時間點最近的
9、開始Please list all universities, colleges and (or) high schools previously attended, beginning with the most recent.學校Name of Institution地點（城市，州，國名）Location (City, State, Nation)修業起迄日期(Attended: fromto )獲頒學位Degree Received主修Major Field讀書計畫Study Plan請提供約三百字左右之讀書計畫，以說明您的學習目的、未來工作目標、申請此科系之理由以及優秀的申請資格等等。
10、Provide a study plan (approximately 300 words) that identifies your academic goals, future career objectives, application reasons to the Department, and other qualifications to strongly approve your application, and so on.申請入學資料核對表Application for Admission Checklist完整的入學申請資料包含下列表單所列項目。請將所有資料放在一完整的申請
11、資料袋內。若資料不完整，將無法進行審核工作。Below is a complete list of application for admission items. Please include all materials in a complete application package. Without complete materials, application review process wont start.標記Mark 繳交資料項目 Application Items份數Quantity(s)入學申請表 Application for admission 2畢業證書原文影本 O
12、fficial photocopy of the diploma 1正式成績單彌封成績單，並請授權單位在彌封處正式簽名Official transcriptsA sealed envelope with the signature ofan authorized official across the seal3推薦信 Letters of recommendation 2讀書計畫 Study plan 1財力證明書存款機構存款種類佐證存款簿影本Financial statementName of bankType of depositA copy of your bankbook as pr
13、oof1健康證明書(包含 HIV 病毒、梅毒血清、麻疹及德國麻疹相關檢查)Health certificate (including a report of HIV, Syphilis, Measles and Rubella tests) 1各項能力證明文件影本 A photocopy of any certificate(s) or license(s)獎學金申請表 Application for Scholarship 1學生證影本 A photocopy of student ID 1身分證明表（如護照影本） Statement of Status (ie. A photocopy o
14、f passport) 1具結書/Declaration一、 本人保證未具僑生身份且不具中華民國國籍。I certify that I hold no status of overseas Chinese, nor nationality of the Republic of China.二、本人在華並未以僑生身份申請其他大學校院。I have not applied to other universities under the status of overseas Chinese.三、本人所提供之最高學歷證書在畢業學校所在地國家均為合法有效取得畢業資格，且所持有之證件相當於中華民國國內各級
15、合法學校授予之相當學位。The certificate of the highest education from home country provided by me is legally acquired and effective, and the graduation certificates of all levels are equivalent to the education of respective levels in the Republic of China.四、本人在華未曾完成申請就學學程或遭退學。I have not completed any applicati
16、on process for study at or expelled from other universities.五、本人上述所陳之任一事項，如有不實或不符規定等情事屬實，本人願依 貴校申請外國學生入學招生辦法之規定辦理。I certify that all of the above information is true, and if any of it is found to be false, I shall have no objection to it being set out in the admission regulations for foreign students.申請人簽名Applicants signature：_日期Date：_
