孔子學(xué)院總部

1、編號(hào)：孔子學(xué)院總部Confucius Institute Headquarters No. 129, Deshengmenwai Street, Xicheng DistrictBeijing P.R. China, 100088 http：/孔子新漢學(xué)計(jì)劃Confucius China Study Plan（CCSP）青年領(lǐng)袖項(xiàng)目申請(qǐng)表Application Form for Young Leaders Subprogram請(qǐng)用中（英）文填寫(xiě)此表格。Please complete the following form in Chinese or English.1

2、. 基本信息 Basic Information姓（以護(hù)照為準(zhǔn)）：Family Name (as shown in passport): 名（以護(hù)照為準(zhǔn)）：Given Name (as appeared on passport)護(hù)照號(hào)碼：Passport No.:國(guó)籍： Nationality:出生日期（年/月/日）：Date of Birth (DD/MM/YY):性別：Gender:男Male女Female母語(yǔ)：Native Language:最高學(xué)歷：Highest Degree:手機(jī)號(hào)碼：Mobile:電子郵件：E-mail：工作或?qū)W習(xí) 工作 working 學(xué)習(xí)studying當(dāng)前工

3、作機(jī)構(gòu)及職務(wù)：Current Working Place and Title: 當(dāng)前就讀學(xué)校及專業(yè)：Current School and Major:當(dāng)前聯(lián)系地址：Current Address:永久聯(lián)系地址：Permanent Address:緊急聯(lián)系人（電話/電子郵件）：Emergency Contact Person（Tel./E-mail）:2. 接受高等教育情況 Background in Higher Education學(xué)校名稱Name of Institution專業(yè)Major起止時(shí)間Year of Attendance所獲學(xué)位Diploma自： 至：From： To：自： 至：

4、From： To：自： 至：From： To：3. 實(shí)習(xí)或工作經(jīng)歷 Internship or Employment機(jī)構(gòu)Employer從事工作Work Engaged起止時(shí)間Years of Service自： 至：From： To：自： 至：From： To：自： 至：From： To： 4. 工作簡(jiǎn)歷、在社會(huì)工作和公共服務(wù)領(lǐng)域所獲榮譽(yù) CV, Awards received in Social Work and Public Service5. 語(yǔ)言能力Language Proficiency中 文： 熟練 較好 一般 Chinese: Fluent Good Fair 英 語(yǔ)： 熟練

5、較好 一般 English: Fluent Good Fair 其他語(yǔ)種：Other languages: 6. 是否曾在華學(xué)習(xí)或工作？Have you ever studied or worked in China?學(xué)習(xí)： 是 否Study: Yes No機(jī)構(gòu)：Institution:起止時(shí)間：Time (from/to):工作： 是 否Work: Yes No機(jī)構(gòu)：Institution:起止時(shí)間：Time (from/to):7. 來(lái)華訪學(xué)計(jì)劃（包括訪學(xué)目的、行程、預(yù)期成果與影響，訪學(xué)后續(xù)活動(dòng)等，中文不超過(guò)500字) Plan of visit in china (Including p

6、urpose, schedule, expected results and effects; subsequent activities after visiting; keep it within 1000 English words)8. 推薦人信息 Information of Referees姓名：Name: 機(jī)構(gòu)：Institution:職稱：Title:聯(lián)系方式：Email:姓名：Name: 機(jī)構(gòu)：Institution:職稱：Title:聯(lián)系方式：Email:11.推薦人的推薦信（電子掃描件）Recommendation Letter（please attach the sca

7、nned letters）:12.其他材料（獲獎(jiǎng)證書(shū)、實(shí)習(xí)評(píng)價(jià)）Other testifying materials （certificate of awards, recommendation for internship）申請(qǐng)人保證： I Hereby Affirm That:l 本表所填寫(xiě)的內(nèi)容和提供的材料真實(shí)無(wú)誤；All information and materials given in this form are true and correct;l 我保證本人身體健康，符合接收院校相關(guān)要求，并于來(lái)華后提交有效的外國(guó)人體格檢查記錄原件；I affirm that I enjoy a

8、 good health that is consistent with the relevant requirements of the host institution. I shall submit valid Physical Examination Record For Foreigners after my arrival in China;l 在華期間，遵守中國(guó)法律、法規(guī)，不從事任何危害社會(huì)秩序的、與本人來(lái)華學(xué)習(xí)身份不相符合的活動(dòng)；During my stay in China, I Shall abide by the laws and decrees of the Chine

9、se government, and will not participate in any activities in China which are deemed to be adverse to the social order of China and are inappropriate to the capacity as a student;l 按規(guī)定期限離華，不無(wú)故在華滯留；I shall leave China according to schedule, and will not extend my stay without valid reasons;l 在華期間，獎(jiǎng)學(xué)金之外所產(chǎn)生費(fèi)用與孔子學(xué)院總部及在華就讀院校無(wú)關(guān)；During my stay in China, expenses incurred apar