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ETS TOEIC® Scholarship Program for Taiwan

Scholarship Application & Questionnaire

This form is designed to collect information about your background, interests, academics, demonstrated leadership, and career plans. Your answers to these questions will be used only in connection with your application for the scholarship program and will be reviewed by an independent scholarship selection committee of professionals. ALL RESPONSES MUST BE PROVIDED IN ENGLISH. Please TYPE or PRINT LEGIBLY. You may attach additional pages as necessary. The completeness, neatness, and legibility of your replies will allow for a complete and comprehensive review of your credentials. ZAPPLICANT INFORMATIONZ

LEGAL NAME

Last/Family Name

First/Given Name

PERMANENT HOME ADDRESS

City

Post Code

TELEPHONE NUMBER

Home Mobile Other

E-MAIL ADDRESS

ID NUMBER

GENDER Female Male

DATE OF BIRTH

/

Day Month

/

Year

ZTOEIC® LISTENING AND READING TESTZ

WHEN DID YOU TAKE THE TOEIC LISTENING AND READING TEST? TEST SCORE REGISTRATION NUMBER

/

Day Month

/

Year

ZTOEIC® SPEAKING AND WRITING TESTSZ

WHEN DID YOU TAKE THE TOEIC SPEAKING AND WRITING TESTS? S SCORE W SCORE REGISTRATION NUMBER

/

Day Month

/

Year

How did the TOEIC test help you achieve your study goals?

ZEDUCATIONZ

UNIVERSITY/SCHOOL YOU ATTEND MAJOR/COURSE OF STUDY

CITY

CURRENT GRADE

ANTICIPATED GRADUATION DATE

/

Month Year

Please list all English proficiency tests taken other than TOEIC.

Test Name Testing Organization Test Date

month/year

Test Scores

List all English language courses or programs you have successfully completed. List the most recent course or program first.

Course or Program Name of School Dates of Attendance

Please list all academic honors and awards you have earned in the past three years, along with the supporting details requested below.

Name of Award or Honor Granting Organization/Institution Date Received

ZCOMMUNITY ACTIVITIESZ

List community agencies or organizations in which you have participated without pay during the last three years. (Religious groups, hospital volunteer, cultural activities, outreach programs, etc.).

Name of Agency or Organization Kind of Activity Dates of Participation # of Hours

per week per year per week per year per week per year per week per year per week per year

If you listed a leadership role in one or more of the activities or organizations cited above, please choose one, detail your responsibilities, and explain the significance of your contribution to the organization.

List part-time jobs/internships (including summer employment) you have held in the last three years.

Employer or Type of Business Job Title or Description Dates of Employment Hours per Week

Of all your courses, activities, internships, and work experience, which one did you find most rewarding or personally satisfying? Explain why.

ZFUTURE GOALSZ

Based on your current achievements and interests, describe the kind of work that you plan to be doing in 5 years, both in your career and in your community.

ZFINANCIAL ASSISTANCEZ

Through what means are you currently funding your higher education? (check all that apply) Parents Loans Self-financed Other ­ please specify:

ZRECOMMENDATION REQUIREMENTZ

One letter of recommendation is required of all applicants. The letter of recommendation should be provided by an English teacher/English professor who is familiar with your academic work. A recommendation form has been provided with this application, to be completed and submitted by your reference. The recommendation form and all accompanying materials must be submitted in English.

ZTERMS & CONDITIONSZ

The ETS TOEIC Scholarship Program for Taiwan is provided by Educational Testing Service (ETS) located in Princeton, New Jersey, U.S.A. All information provided in your application and associated documents submitted to the scholarship program (including interviews) must be accurate and truthful, not misleading, or misrepresent or omit any facts that are relevant. If ETS finds significant errors or omissions in the information you have supplied to us in the course of your application, or that you have not met all of the eligibility requirements set forth by ETS, ETS may decide not to offer you a scholarship, or to withdraw or terminate a scholarship if it has been awarded.

ZAUTHORIZATION/CERTIFICATIONZ

Please review your responses and sign your name below. By signing below you certify that all information contained in this application and associated documentation is accurate and true and that you explicitly consent to (and have obtained such consent from any individual whose personal information you have included as part of this application) having the information provided in this application and associated documentation, and as required by this application, to be used by Educational Testing Service, Chun Shin Ltd., and their third party service providers for purposes of the ETS TOEIC Scholarship Program for Taiwan, and that this information may be transferred to and processed in the United States. Further, by signing below, you agree to all of the conditions and requirements set forth by ETS with regard to the ETS TOEIC Scholarship Program for Taiwan. Name of Applicant (Please Print) Signature of Applicant IMPORTANT: Date

Your application will not be considered complete unless all of the following materials are received by Chun Shin Ltd. on or before October 31, 2010 Scholarship Application & Questionnaire (this form) A copy of your valid TOEIC Listening and Reading Score Report*/Certificate OR TOEIC Speaking and Writing Tests Score Report* A copy of your latest official transcript, issued by the school at which you are currently registered One letter of recommendation provided by an English teacher/professor (using the provided Recommendation Form) An English autobiography Related Credentials * In order to apply for the ETS TOEIC Scholarship Program for Taiwan, you must submit a valid TOEIC score. Score Reports are valid for two years from the date of the test administration.

IT IS YOUR RESPONSIBILITY to ensure that the required materials are submitted to Chun Shin Ltd. no later than October 31, 2010, even if another person is placing the material in the mail. Submit all required materials to: Attention: ETS TOEIC Scholarship Program Chun Shin Ltd. Address: 2F, No.45, Sec.2, Fu-Xing S. Rd Da-an District, 10665 Taipei, Taiwan(R.O.C.) : : ZIP: TOEIC 2 452 10665

If you have any questions, please contact Chun Shin Ltd. at +886-2-2701-7333 or [email protected]

ZPRIVACY STATEMENTZ All materials submitted to support an application in the scholarship program are used only in the selection process. If you are named a scholarship recipient, your folder will remain in active status during the period that the scholarship is in force, and will be retained for one year thereafter. All records are confidential and available for reference by program management staff.

Administrative services for the ETS TOEIC Scholarship for Taiwan are provided by Scholarship & Recognition Programs, a unit of Educational Testing Service. Copyright © 2010 Educational Testing Service. All rights reserved.

ETS, the ETS logo, and TOEIC are registered trademarks of Educational Testing Service (ETS) in the United States of America and other countries throughout the world.

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Microsoft Word - ETS TOEIC Sch Pgm for Taiwan SQ.docx