Chinese Name

中  文  名

English Name

(as shown on your passport)

 英文名（与护照一致）

Family Names姓         Given Names名

Nationality

国    籍

Gender

性    别

Male男 □

Female女 □

Marital Status

婚姻状况

Single单身□Married已婚   □

Divorced 离异   □

Place of birth

出生地

Date of birth

出生日期

PassportNo.

护照号码

Passport Valid

护照有效期

Highest Education

LevelObtained

最后学历

Student Category

学生类别

□Four -year Students with diploma     

□Chinese Language Student

□Exchange Student

□Other _________   

Which School do you study in QNU?

所在学院

Which Major do

you study inQNU

学习的专业

Study Period inQNU

学习时间

From:To:         (yy/mm/dd)

从：         至：          (年/月/日)

Financial Support

经费来源

□ Self-supported Student  自费生                                        

Tuition：_________ RMB /Academic year

Scholarship class applied

申请奖学金等级

□first-class scholarship   一等奖学金  

□second-class scholarship 二等奖学金

□third-class scholarship   三等奖学金

Contact information

联系方式

Wechat No.微信号

Mobile手机

Email电邮

Postal Address通讯地址

Self-evaluation

自我评价

Study Plan

学习计划

Applicant’s Signature                                                       Date

申请人签名                                                              日期：

Notice:  Please print the two pages of the form on the same paper.