Jinggangshan University

28

343009

28 Xueyuan Road Jian, Jiangxi, P. R. China 343009

Scholarship Application Form for International Students

in English

Name

in Chinese

Nationality

Sex

Male

(3.5cm4.5cm)

Female

Date of Birth

Place of Birth

No

Health Status

Religion

Education

Occupation

Passport No.

Valid until

(TEL):

Mailing Address

(FAX):

Junior

Average

Chinese Level

Photo

Yes

Marital Status

Good

E-mail

Chinese Language Students

Undergraduate

Categories of foreign students

Duration :

From 2016 Y 09 M

01 D

To

2020 Y 09 M

31 D

Specialty

Civil Engineering

I hereby affirm that:

1. All the information given in this form is true and correct.
2. I shall abide by the laws of the Chinese Government and the regulations of the
school.

Signature

Date

Applicant should submit the following documents with the application form:
1. Photocopy of your High School certificate
2. Filled in Medical Form
3. The copy of your passport


PHYSICAL EXAMINATION RECORD FOR FOREIGNERS

Name

Sex

Male
Female

Birth Day-Month-Year

Present mailing address

Blood
type

Nationality

Birth Place

Photo
(stamped
Official Stamp)

Have you ever had any of the following diseases?

(Each item must be answered yes or No

Typhus fever

No Yes

Poliomyelitis

No Yes

Diphtheria

No Yes

Bacillary dysentery

No Yes

Brucellosis

No Yes

Viral hepatitis

No Yes

Scarlet fever

No Yes

Puerperal streptococcus infection

Relapsing fever

No Yes

No Yes

Typhoid and paratyphoid fever

No Yes
No Yes

Epidemic cerebrospinal meningitis

Do you have any of the following diseases or disorders endangering the pubic order and security?
(Each item must be answered Yes or No)

ToxicomaniaNo Yes

Mental confusionNo Yes

Psychosis: Manic psychosisNo Yes

Paranoid psychosisNo Yes
Hallucinatory psychosisNo Yes

Height

cm

Weight

Development

Nourishment

Vision

Corrected vision

L
R

kg

Blood pressure

Neck

L
R

Eyes

Colour sense

Skin

Lymph nodes

Ears

Nose

Tonsils

Heart

Lungs

Abdomen

KPa

Spine

Extremities

Nervous system

Other abnormal findings

X

Chest X-ray

Exam

ECG

(Attached
chest X-ray
report
(1)

HIV

HIV (ELISA)

(3)

Laboratory exam

(2)

Syphilis serum agglutination reaction

(Attached test
report of AIDS,
Syphilis etc)

None of the following diseases or disorders found during the present examination

Cholera

Yellow fever

Plague

AIDS

Leprosy

Psychosis

Signature of physician

lung tuberculosis

Suggestion

Venereal Disease

Official Stamp

Date