國立臺灣師範大學外國學生入學申請表

Application for International Student Admission of National Taiwan Normal University

申請季別
2024 春 SPRING 2024 (Deadline: 2023/07/31 )
Applying for Term
文件碼
(請確認是否與系統上的編碼一致)
EB3F-B8D6
Doc. Code (Please double check if the code is the same with
the one on the system)
申請就讀之系所及學位 Which department/graduate institute and degree do you wish to apply for at NTNU?
系所 華語文教學系
Department /
Graduate Institute Department of Chinese as a Second Language

組別
Division
學位 碩士 授課語言
中文 Chinese
Degree Master’s Language of Instruction

申請編號
Application No. 728402010

申請人姓名
Applicant's Name 夏愛恬 EDELWEIS DENISE IVORY

出生日期 性　別 出生地

2001/02/16 女 Female Medan
Date of Birth Gender Birth Place
國　籍 印尼 Indonesia 護照號碼 E3208822
Nationality Passport No.
行動電話 電子郵件
0908734790 [email protected]
Cell phone E-mail
電　話 通訊地址
0908734790 [email protected]
Telephone Mailing Add.

申請人之父親 出生日期 國　籍

Patar Mangasi Siregar 1967-01-08 印尼 Indonesia
Applicant’s Father Date of Birth Nationality

申請人之母親 出生日期 國　籍

Junita Srihayu 1972-06-08 印尼 Indonesia
Applicant’s Mother Date of Birth Nationality

聯絡人姓名 與申請人關係 電　話

Junita Srihayu Relationship Mother 081241054289
Contact Name Telephone

教育背景 Educational Background

學位 學校名稱 學校所在地 主修學門 副修學門 學位 取得學位日期
Degree Name of School City and Country Major Minor Degree Date Degree Granted
Sungailiat City, Office
高級中學 Vocational High School Bangka Island, Administra Administra - 2018/05/03
No. 1 tion
High School Indonesia tion
Linkou District, Business Marketing
大學 / 學院 Hsing Wu University New Taipei City, Administra and - 2022/06/30
University / College Taiwan tion Logistic
研究所
Graduate Institute

第 1 頁
財力支援狀況：在本校求學期間費用來源
Financial Support: What will be your major source of financial support during your studies at NTNU?

☐ 個人儲蓄 ☐ 父母支援 ☑ 獎助金 ☐ 其他來源

Personal Savings Parents Scholarship Other Source

獎學金 Scholarship

您目前領取的獎學金項目 (Scholarship currently applying for or being awarded):

☑ 教育部/科技部 臺灣獎學金MOE/MOST Taiwan Scholarship

☐ 外交部臺灣獎學金 MOFA Taiwan Scholarship, 受獎期間 Award Period: / ~ /

☐ TaiwanICDF獎學金 TaiwanICDF Scholarship

☐ ESIT Program獎學金 ESIT Program Scholarships

☐ Mekong 1000 Program

☐ ECV1000 (Eastern Central Vietnam)
☐ Aceh Government Scholarship Program
☐ DIKTI Vocational Lecture Program
☐ Elite 600 Scholarship Program
☐ Elite Scholarship Program

☐ 其他，請註明 Other, please specify:

是否申請師大獎學金 (Would you like to apply for NTNU scholarship)

是 Yes

中文語文能力 Chinese Language Proficiency

學習中文幾年? 3 年 year 0月 month(s)

How many years have you studied Chinese?

☐ 本校國語教學中心 Mandarin Training Center (MTC) at NTNU

學習中文環境(可複選) ☐ 高中 high school
Where did you study Chinese? ☑ 大學 university/college
(Multiple selections accepted)
☐ 當地語言機構 local language institute:

☐ 臺灣其他大學語言中心 other Chinese language center/institute in Taiwan:

☑ 是 Yes
☑ 華語文能力測驗 (TOCFL) Test of Chinese as Foreign Language 3
您是否參加過中文語文能力測驗?
☐ 新漢語水平考試 (HSK) Hanyu Shuiping Kaoshi (HSK):
Have you taken any Chinese
proficiency test? ☐ 其他，請註明測驗名稱及分數Other, please specify the name of the test and the score:

☐ 否 No

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中文能力自我評估 Please evaluate your Chinese language skills.

聽 Listening 佳 Good

說 Speaking 佳 Good

讀 Reading 佳 Good

寫 Writing 佳 Good

英文語文能力 English Language Proficiency

☑ 是 Yes
☐ 托福 iBT TOEFL iBT Total Score:
您是否參加過英文語文能力測驗? ☐ 雅思總分 IELTS Overall Band Score:
Have you taken any English proficiency ☑ 多益聽讀總分 TOEIC (Reading and Listening) Total Score: 750
test? ☐ 其他，請註明測驗名稱及分數Other, please specify the name of the test and the score:
☐ 否 No
英文能力自我評估 Please evaluate your English language skills.

聽 Listening 佳 Good

說 Speaking 尚可 Average

讀 Reading 佳 Good

寫 Writing 佳 Good

您是如何得知本校外國學生招生訊息（可複選）
How did you learn about NTNU international student admission? (Multiple selections accepted)

☐ 親戚/朋友/老師告知Through relative/friend/teacher
☐ 本校國語中心 Mandarin Training Center at NTNU
☑ 師大網站 NTNU website (http://en.ntnu.edu.tw/)
☐ Study in Taiwan網站Via Study in Taiwan website
☐ 臉書/ YouTube廣告 Ads on Facebook/YouTube
☐ 雜誌廣告 Magazine advertisement
☐ 招生海報、手冊、簡章 Posters, brochures, or admission prospectus
☐ 大使館、駐外機構、海外臺灣教育中心 ROC embassies, diplomatic missions, or Taiwan Education Centers
☐ 海外留學機構 (請填寫機構名稱)：Study abroad agencies:

☐ 線上教育展(網站)、說明會 (請提供網址或註明場次)：Virtual education fairs (website) or webinars:

☐ 招生教育展、說明會 Traditional education fairs:

☐ 其他，請註明 Other, please specify:

第 3 頁
 具　結　書 DEPOSITION

1. 本人已閱讀、瞭解並保證符合臺灣教育部公告之「外國學生來臺就學辦法」之申請資格。
（http://law.moj.gov.tw/LawClass/LawAll.aspx?PCode=H0110001）
I have read and understood the Regulations Regarding International Students Undertaking Studies in Taiwan issued by the
Ministry of Education and hereby affirm that I meet the definition of "international student" as specified therein.
(http://law.moj.gov.tw/LawClass/LawAll.aspx?PCode=H0110001)

2. 本人所提供之最高學歷畢業證書(報名學士班者為高中畢業證書，研究所者為大學或碩士畢業證書)在畢業學校所在國家
均為合法有效取得畢業資格，並所持之證件相當於中華民國國內之各級合法學校授與學位。
The diploma I provided (secondary degree diploma for applying for undergraduate program, bachelor or master's degree for
graduate program) is valid in the home country of the conferring school, and equivalent to the degree conferred by lawful academic
school in the ROC.

3. 本人在臺未曾因操行不及格或因刑事案件經判刑確定致遭大學院校退學。
I have never been dismissed from schools in Taiwan after admission due to behavior issues, poor academic performance or a
conviction under the Criminal Law.

4. 本人保證未曾以僑生身分在臺就學，且未於當學年度接受海外聯合招生委員會分發。
I hereby certify that I have never studied as an overseas Chinese student in Taiwan nor received placement permission during the
same year of the application by the University Entrance Committee for Overseas Chinese Students.

5. 本人了解來臺就學期間在臺辦理戶籍登記、戶籍遷入登記、歸化或回復中華民國國籍者，貴校應予退學並喪失外國學生
身分。
I understand that during the course of study in Taiwan, I am approved for initial household registration, resident registration,
naturalization or restoration of their R.O.C. nationality, will lose my international student status and shall withdraw from NTNU.

6. 本人保證已閱畢貴校外國學位生申請入學簡章，並了解逾期繳件或未依規定繳交完整且正確申請文件貴校不予受理，本
人絕無異議。
I hereby certificate I have read through “Application Prospectus for International Students” and understand late submission,
incomplete or incorrect submission is not acceptable. The decision by NTNU is final and irrevocable.

7. 本人保證提供之所有申請相關資訊及文件均為合法有效之文件，並同意授權貴校查證，如經查證有不實之情事，本人同
意貴校取消其申請資格或撤銷學籍(已入學者)，絕無異議。
I hereby certify that all application related information and documents I provided are legal and valid. Moreover, I hereby authorize
NTNU to check on any of my submitted information and document. If any of it is found to be false, I will accept the consequences
of deprivation of my application or admission(enrolled student). The decision by NTNU is final and irrevocable.

8. 上述所陳之任一事項同意授權 貴校查證，如有不實或不符規定等情事屬實者，本人願依 貴校相關規定辦理，絕無異議

。
I agree to authorize the National Taiwan Normal University to verify any information provided above. I am willing to follow the
rules and regulations of National Taiwan Normal University without any objections should the information provided be found
untruthful.

文件碼
(請確認是否與系統上的編碼一致)
Doc. Code EB3F-B8D6
(Please double check if the code is the same
with the one on the system)

申請人簽名 日期
Signature Date

第 4 頁