APPLICATION FOR ADMISSION

※Application Deadline (Documents must be received by YZU)：April 15, 2014

Please type or print CLEARY in English.

Applicant’s Name / (In English)
(Family Name) (Given Name) / Date of Birth /
(mm) (dd) (yyyy)
(In Chinese) / Gender / □Male□ Female
E-mail / Telephone
Permanent Address
Mailing Address
MSN Messenger / Skype Account
Nationality / Passport No. / Alien Resident Certificate No.

Information about Applicant’s Parents

Father’sName / Father’sNationality
Mother’sName / Mother’sNationality

Education

Degree / Name of School / City and Country / Major field of study / Minor / Duration of study / Degree/Diploma/
Certificate / Date of Degree Granted
High School / From:
/
(month/year)
To:
/
(month/year)
Undergraduate / From:
/
(month/year)
To:
/
(month/year)
Postgraduate / From:
/
(month/year)
To:
/
(month/year)
Work Experience

（Continued on the nextpage）
Degree program for which you are applying: (Check  ONE)

Academic Unit / Degree
Bachelor / Master / Doctor
College of Engineering
Department of Mechanical Engineering
Department of Chemical Engineering and Materials Science
Department of Industrial Engineering and Management / 
Graduate School of Biotechnology and Bioengineering
GraduateSchool of Renewable Energy Engineering
College of Informatics
Department of Computer Science and Engineering
Department of Information Management
Department of Information Communication: Network Communication
Department of Information Communication: Digital Media Design
Department of Information Communication: Interactive Edutainment Technology
GraduateSchool of Social Informatics
Biology and Bioinformatics Program
College of Management
Department of Business Administration
Department of Finance
Department of International Business
Department of Accounting
Graduate School of Management– Technology and Services Innovation
Graduate School of Management– Marketing Management
Graduate School of Management– Organization Management
Graduate School of Management– E-business and Services
GraduateSchool of Management - Finance
Graduate School of Management– International Business Management
GraduateSchool of Leadership
Graduate School of Service and Technology Management
College of Humanities and Social Sciences
Department of Foreign Languages and Applied Linguistics
Department of Chinese Linguistics and Literature
Department of Social and Policy Sciences
GraduateSchool of Visual Arts Management
Department of Art Creativity and Development
College of Electrical and Communication Engineering
Department of Electrical Engineering
Department of Communications Engineering
Department of Electro-Optical Engineering

English Proficiency

Standardized Test : TOFEL(iBT)/TOFEL(PBT)/TOEIC/IELTS/Cambridge ESOL/GEPT/CSEPT
Test:Date Taken/to be taken :/ (month/year) Score:
Self evaluation of English Proficiency
Listening:□Excellent □Good □Fair □Poor / Speaking:□Excellent □Good □Fair □Poor
Reading: □Excellent □Good □Fair □Poor / Writing:□Excellent □Good □Fair □Poor

Chinese Proficiency□I cannot speak/write/read/listen to Chinese.

Standardized Test : TOP Writing/TOP Speaking/TOP Reading/CPT/HSK
Test:Date Taken/to be taken :/ (month/year) Score:
Chinese Language Courses Taken (where and how long):
The Chinese school(s) I am attending/have attended (where and how long):

Application for Scholarships

□I am applying for waiver of tuition and fees. / □I am applying for dormitory accommodations.
□I am applying for monthly stipend. / □I have applied for Taiwan Scholarships.
□I have applied for TaiwanICDF Scholarships.

Applicant’s Signature ______Date ______

Declaration

  1. I hereby certify that I do not hold the nationality of Republic of China. (Please refer to the Article 2 of the Nationality Law of Republic of China for the definition of ROC Nationality)*

＊According to the Article 2 of Law of Nationality, A person shall have the nationality of the Republic of China under any of the conditions provided by the following subparagraphs:

(1) His/Her father or mother was a national of the Republic of China when he/she was born.

(2) He/She was born after the death of his/her father or mother, and his/her father or mother was a national of the Republic of China at the time of death.

(3) He/She was born in the territory of the Republic of China, and his/her parents can’ t be ascertained or both were stateless persons.

(4) He/She has undergone the nationalization process.

  1. I hereby certify that I do not possess overseas Chinese status and had never applied for colleges/universities with the overseas Chinese status.
  1. I hereby certify that I did not complete high school in Taiwan with a foreign student status, or was never expelled form colleges/universities in Taiwan.
  1. I hereby certify that I do not hold the nationality of People’s Republic of China or the citizenship of Hong Kong or Macau.
  1. I hereby certify that I have renounced, if once held, the nationality of Republic of China for more than 8 years till the date school begins.
  1. I hereby certify that the certificate/diploma of the highest degree I provide is valid and authentic.
  1. I hereby authorize the YuanZe University to verify the information provided above. I am willing to follow the rules and regulations of the YuanZe University without any objections should the information provided be found untruthful.

Applicant’s Signature

______Date______

Check List

The following documents together with the completed application form need to be submitted to the Department of Industrial Engineering & Management at the Yuan Ze University.

Check
() / Document / No. of copies
Check list / 1
The completed application form / 1
Declaration Form / 1
Photocopy of the diploma (or provisional certificate) of the highest degree received.
*If the diploma is not written in English or Chinese, its translation in English or Chinese needs to be attached. / 1
Photocopy of the transcript of academic records
*If the transcript of academic records is not written in English or Chinese, its translation in English or Chinese needs to be attached. / 1
Letters of recommendation / 2
Curriculum Vitae / 1
Statement of Purpose / 1
Official score report of an English proficiency standardized test, such as TOFEL(iBT)/TOFEL(PBT)/TOEIC/IELTS/Cambridge ESOL/GEPT/CSEPT. (Required for the application for the admission to the Master programs of Business Administration, International Business, and Accounting) / 1
TaiwanICDF Medical Report / 1
Official score report of a Chinese proficiency standardized test (TOP/HSK)
(Required for the application for the admission to the Department of Chinese Linguistics and Literature) / 1

The following documents need to be submitted to the Department of Industrial Engineering & Management at the Yuan Ze University once you are admitted to the University:

Check
() / Document / No. of copies
Certificate of nationality (passport, residence certificate or birth certificate) / 1
The diploma (or provisional certificate) of the highest degree received authenticated by theROC (Taiwan) Embassy or representative office. / 1
Transcript of academic recordsauthenticated by theROC (Taiwan) Embassy or representative office. / 1
2-inch (4.5 cm x 3.5 cm) photos (For more photo regulations, please view the website: / 4
Certificate of nationality renouncement of Republic of China (if applicable) / 1

Applying for: Yuan Ze University (YZU)

International Master’s Program in Industrial Engineering and Management

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

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

☆Yuan Ze University (YZU) reserves the right to require the applicant to undergo a future medical examination after he/she arrives in the Republic of China (Taiwan).

Applying for: International Master’s Program in Industrial Engineering and Management, YZU

PART 1: HEALTH DECLARATION

Nationality:

Name:(Last)

(First)

(M. Initial)

Gender: Male□Female□Date 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 notethat 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.

Name of Applicant:Date of Birth

Y/ M/ D/

Physical Examination:
HEIGHT：
BLOOD PRESSURE： / cm
/ mmHg / WEIGHT：
PULSE RATE： / kg
/min
VISUAL ACUITY： / R L
EYES：□normal □color anomalous □other
EAR/NOSE/THROAT：□normal □auditory meatus abnormal □cleft lip and palate
□impending infarction □allergic rhinitis □chronic rhinitis □other
NECK：□normal □wryneck □goiter □the lymphoid swelling of gland is big □other
CHEST：□normal □thoracic anomaly □core noise □arrhythmias □other
CHEST X RAY：□normal □advertise for like the tuberculosis □pleura effusion □thoracic abnormality
□tuberculosis calcify □the spinal column side is curved up □cardiac hypertrophy
□bronchiectasis □other
ABDOMEN：□normal □hepatomegaly □splenomegaly □hernia □other
SPINALCOLUMN ARMS AND LEGS：□normal □scoliosis □frog limb □articulation deformity
□edema □other
SKIN：□normal □wart □purple plague □scabies □a dermatitis □other
MOUTH CAVITY：□normal □oral hygiene is poor□calculus□gingivitis □milk tooth □other
Urine Test:
NAD WBC RBC PROTEIN CLUCOSE
Hepatitis B Test:
POSITIVE / NEGATIVE
Serological Test for Syphilis:
POSITIVE / NEGATIVE
HIV Test:
POSITIVE / NEGATIVE
THE ORIENTATION INSTITUTION WILL REQUIRE A FURTHER HIV TEST AFTER HE/SHE ARRIVES IN ROC (TAIWAN). THE ONE WITH POSITIVE TEST RESULT WILL BE REJECTED AND SENT BACK HOME IMMEDIATELY.
Pregnancy Test:
POSITIVE / NEGATIVE
Is the applicantnow under treatment for any physical or emotional condition?
………………………………………………………………………………………………………
Do you have any recommendations for the health care of this applicant?
………………………………………………………………………………………………………
By history and physical examination, is this applicanta carrier of any communicable disease?
………………………………………………………………………………………………………
CERTIFICATION BY THE MEDICAL OFFICER:
I certify that I have examined the above applicant and in my opinion:
□The applicant is medically fit to undertake a program in Taiwan
□The applicant suffers mental or physical defects and is NOT in good health
Name of physician, Title / :…………………………………………………
Name of Hospital / Clinic / :…………………………………………………
Address / :…………………………………………………
:…………………………………………………
:…………………………………………………
Not valid if without the hospital or clinic’s seal