NKNU CLCT

2014 Application Form

Spring

Summer Fall Winter

2014

General Course
Individual Class

$10,500 (20hrs) $6,500 (10hrs)

Full Name in Chinese

Full Name in English as shown

Education

Major

Profession

Employer

on your passport (including punctuations)

Vegetarian
Non-Veg
(other:______)

Diet

$26,660 $23,490
$27,050 $23,895
$26,660 $23,490

Nationality

Date of Birth

YY/MM/DD

Sex

Male

Female

Visa : Visitor(Student )

Passport No.

( ARC) (Working Holiday)(other):___

Address in Taiwan

Permanent Address
Local:

Mobile:

Email Address
Address

Contact person in Taiwan

Phone No.

Phone No.

How long do you plan to study Chinese at CLCT: ______ Year(s)____ Month(s)
Please submit the following application materials:
Submitted
2

Application form and Two 1 or 2 photos

Photocopy of passport first page (passport number, full name and photo must be clearly shown)

Photocopy of diploma

X
Health Checkup Report within 6 months (HIV test, Chest X-Ray and Rubella antibody test included

()
Financial Statement, showing at least US$2,000. If statement is in your parents name, you must also submit their signed
guarantee letter promising financial support.

Recognizance of Insurance Plan

-
1.

2.

3.
I , applying for 2013-2014 Mandarin Classes at CLCT, NKNU, certify that:
1. I am aware that according to the governments law, I cannot work full time or part time under the illegal working conditions; if I violate the law, I will
drop out unconditionally and will not apply for refund.
2. I am aware that students at CLCT must join the group insurance plan; if I request a waiver, I must sign a recognizance, and I myself am fully
responsible for accident payments
3. I have read and will abide by all of the enrollment regulations.

I have read and understood the regulations above. I certify that the information given in this application is accurate and complete to the best of my
knowledge, and I understand that I must take full responsibility of any consequence resulting from my false statements and/or unrecognizable handwriting
within this application. (Applicants representative must abide by the recognizance above.)

(Applicants Signature):

(Date):

Center of Language and Culture Teaching, National Kaohsiung Normal University
80201 116
No.116, Heping First Road, Lingya District, Kaohsiung City 80201, Taiwan, R.O.C.
TEL: 886-7-7172930 # 2603
FAX: 886-7-7166903
Email: clcts9286@gmail.com
Website: www.nknu.edu.tw/~clct/
CLCTNKNU 2013. All rights reserved.

None of the application materials are returnable. CLCT reserves the right to issue admission

 NKNU CLCT

SURVEY OF THE APPLICANTS LANGUAGE BACKGROUND

New Student Only
Native Language
Nationality

Name

1.
Do you prefer your classmates from the same language background?(For reference only)
Yes

No

No comment

2. What study materials have you used in your study of Chinese? (Please answer in detail.)

3. Have you studied Chinese?

Yes
(What kind of phonetic system did you learn before? pinyin )
No
4. a).
How long have you been studying Chinese? (Please answer in detail.)
_______________(___ _ hr/per week, for _ __years ___months)
b). __________(

years

months in total )

c). Where did you learn Chinese? __________________

5. Can you speak Chinese?
Yes ( fluent

fair a little)

No

6. Can you read Chinese? Yes ( fair a little)

No

If you answered yes, you can read:

standard characters

simplified characters

7. Can you write Chinese? Yes ( fair a little)

No

If yes, please answer the following questions.

Which characters can you write? Multiple options are possible.
standard characters simplified characters
8. How long have you lived in a Chinese language environment?
________ years ________ months
This was in Taiwan China Hong Kong Other (Please specify:___________)
9. Have you ever taken a Chinese Proficiency Test?
Yes

No

If yes, please answer the following questions.

Test of Chinese as a Foreign Language
Listening &Reading

Speaking Writing

_____ (Proficiency Level)

CPT (in America) Score_________________(points)

SATII-Chinese (in America) Score_________________(points)
HSK (in Mainland China) Certificate

_______ (Proficiency Level)

(in Japan) Certificate

_______ (Proficiency Level)

TECC (in Japan) Score_________________(points)

CLCTNKNU 2013. All rights reserved.


____/____/____

Hospitals
Logo

() () ()
____/____/____
() () ()

ITEMS REQUIRED FOR HEALTH CERTIFICATE Form B

Date of Examination

Hospitals Name, Address, Tel, FAX

Name
_________________

_________________
ID No.

Date of Birth

Age

_________________

( BASIC DATA)

Male Female
Sex

_________________
Passport
No.

Nationality _________________

Photo

Phone No. _________________

(LABORATORY EXAMINATIONS)

A. HIV Serological Test for HIV Antibody

Positive

Negative

.Screening Test EIA

PA

Indeterminate
Others______________

.Confirmatory Test
Western Blot

Others______________

15 (Not required for children under 15 years of age)

B. X Chest -Ray for Tuberculosis

X (Findings)
(Results)
(Passed)

(TB Suspect)

( Pending)

(Failed)

(
) (Those who are determined to be TB suspects or have a
pending diagnosis by the designated hospital in Taiwan must visit the referred institution for further
evaluation.)
12 (Not required for pregnant women or children under 12 years of age)
C.Stool examination for
parasites includes Entameba histolytica etc.(centrifugal concentration method)
( Positive, Species ) ______________________ Negative
(Other parasites that do not require treatment) ____________________
6 (Not required for children under 6 years of age or applicants
from designated areas as described in Note 6)
D.Serological Test for Syphilis

(Tests).RPR VDRL ______________ .TPHA/TPPA _______________

.Other___________
(Results)(Passed)

(Failed)

15 (Not required for children under 15 years of age)

E.proof of positive measles and rubella antibody

titers or measles and rubella vaccination certificates

a.Antibody test )
measles antibody titers
Positive
Negative Equivocal
rubella antibody titers Positive
Negative Equivocal
b. Vaccination Certificates
()
(The Certificate should include the date of vaccination, the name of administering hospital or clinic and
the batch no. of vaccine; the date of vaccination should be at least two weeks prior to going abroad)
Vaccination Certificates of Measles
Vaccination Certificates of Rubella
c. (Having contraindications, not suitable for vaccination)

EXAMINATION FOR HANSENS DISEASE

(Skin Examination)
Normal
Abnormal (not related to Hansens disease)
()(Hansens disease suspect needs further exam)
.(Skin Biopsy)
.(Skin Smear) ( Finding bacilli in affected skin smears )
Negative
c.( Skin lesions combined with sensory loss
or enlargement of peripheral nerves ) Yes No
(Results)(Passed)
(Failed)
(Not required for applicants from designated areas as described in Note 6)
(Note)
This form is for residence
application.
6 ( 1 1 ) A
child under 6 years old is not necessary to have laboratory examination, but the certificate of vaccination is necessary. Child
age one and above should get at least one dose of measles and rubella vaccines.
12
X Pregnant women and children
under 12 years of age are exempted from chest X-ray examination. Pregnant women should undergo chest X-ray after the
childs birth.
X
X
15 HIV
A child under 15 years old is not necessary to have Serological
Test for HIV or Syphilis.

Applicants living in USA, Canada, Europe, New Zealand, Australia, Japan, South
Korea, Hong Kong, Macao, Singapore or Israel are not required to undergo a stool examination for parasites or an examination
for Hansens disease.

Hansens disease examination refers to careful examination of the entire body

surface, which should be done with courtesy and respect to the applicants privacy. During the examination, the applicant is
allowed to wear underwear and be accompanied by a friend or female medical personnel. Hospitals or clinics have the
responsibilities to protect the privacy of the applicant and the examination should be done step by step. Hence, taking off all
clothes at the same time should be avoided.

//

ResultAccording to the above medical report of Mr./Mrs./Ms.
, he/she
has passed the examination has failed the examination needs further examination.

(Chief Medical Technologist)

( Chief Physician )

Name Signature

Name Signature

( Superintendent )

Name Signature

Date

Valid for Three Months

(WB)

()
()

()()

Entamoeba histolytica

Entamoeba hartmanni

Entamoeba coli
Endolimax nana
Iodamoeba
butschlii
Dientamoeba fragilis
(Chilomastix mesnili)

RPR VDRL TPHA(TPPA)

RPR(+) VDRL(+) TPHA (TPPA)=1320

320

VDRL

()

Appendix: Principles in determining the health status failed

Test Item
Principles on the determination of failed items
Serological Test 1. If the preliminary testing of the serological test for HIV antibody is positive for two consecutive times,
for HIV
confirmation testing by WB is required.
Antibody
2. When findings of two consecutive WB testing (blood specimens collected at an interval of three
months) are indeterminate, this item is considered qualified.
Chest X-ray
1. Active pulmonary tuberculosis (including tuberculous pleurisy) is unqualified.
2. Non-active pulmonary tuberculosis including calcified pulmonary tuberculosis, calcified foci and
enlargement of pleura, is considered qualified.
Stool
1. By microscope examination, cases are determined unqualified if intestinal helminthes eggs or other
Examination for protozoa such as Entamoeba histolytica, flagellates, ciliates and sporozoans are detected.
Parasites
2. Blastocystis hominis and Amoeba protozoa such as Entamoeba hartmanni, Entaboeba coli, Endolimax
nana, Iodamoeba butschlii, Dientamoeba fragilis, Chilomastix mesnili found through microscope
examination are considered qualified and no treatment is required.
3. Pregnant women who have positive result for parasites examination are considered qualified and
please have medical treatment after the childs birth.
Serological Test 1. After testing by either RPR or VDRL together with TPHA(TPPA), if cases meet one of the following
for Syphilis
situations are considered failing the examination.
(1)Active syphilis: must fit the criterion (1) + (2) or only the criterion (3).
(2)Inactive syphilis: only fit the criterion (2).
2. Criterion:
(1)Clinical symptoms with genital ulcers (chancres) or syphilis rash all over the body.
(2)No past diagnosis of syphilis, a reactive nontreponemal test (i.e., VDRL or RPR), and
TPHA(TPPA)1320(including 1320)
(3)A past history of syphilis therapy and a current nontreponemal test titer demonstrating fourfold or
greater increase from the last nontreponemal test titer.
3. Those that have failed the serological test for syphilis but have submitted a medical treatment
certificate are considered passing the examination.
Measles,
The item is considered unqualified if measles or rubella antibody is negative (or equivocal) and no
Rubella
measles, rubella vaccination certificate issued after the antibody test is provided. Those who having
contraindications, not suitable for vaccinations are considered qualified.
03/06/2012

( 2013-06-18 )
The List of Hospitals in Kaohsiung, Taiwan, Allowed to Execute Health Examination for
Foreigners
Name of Hospital

/ Address and Tel number

807 100

No.100 , Tzyou 1st Road, Kaohsiung

Kaohsiung Medical University
City 807
Chung-Ho Memorial Hospital
07-3121101

Zuoying Branch of Kaohsiung Armed

Forces General Hospital

104 6 30

813 553
No.553, Junxiao Rd., Zuoying Dist.,
Kaohsiung City 813

103 12 31

(07)581-7121
162

Yuans General Hospital

Kaohsiung Municipal Hsiao-Kang

Hospital

Kaohsiung Municipal TA-TUNG

Hospital

Kaohsiung Chang Gung Memorial

Hospital of the C.G.M.F

No.162, Chenggong 1st Rd., Lingya

Dist., Kaohsiung City 802
(07)335-1121~31

104 6 30

482
No.482, Shanming Rd., Siaogang Dist.,
Kaohsiung City 812
07)803-6783

104 6 30

80145 68

No.68, Jhonghua 3rd Rd, Cianjin

District, Kaohsiung City 80145
(07) 291-1101

105 12 31

123
No.123, Dapi Rd., Niaosong Dist.,
Kaohsiung City 833
07731-7123

103 12 31

82445 1

No.1, Yida Road, Jiaosu Village,

E-Da Hospital

Yanchao District, Kaohsiung City 82445

07-6150011

103 12 31

NKNU CLCT
Recognition of Insurance Plan (English Version)
General Instruction:
The University requires all enrolled students to join Insurance Plan that meets certain criteria. The
Insurance Plan of Center of Language and Culture Teaching (CLCT) is now provided by Nanshan
Life Insurance Company. Students are responsible for insurance fee.
Please Note:
Default enrollment is designed as a final measure to enforce the requirement. The insurance fee is
NT$377 per semester (3 months) for the academic year 2014, and is not included in tuition fee.
Students who have questions referring to the insurance service should contact Miss Wu in charge of
CLCT student insurance. Students who want to request a waiver must fill in the recognizance form
below:

I, _________________________________Passport Number____________________,
(First Name/ Middle Initial/ Last Name )
born in ______________________________State of ____________________________
(Country)
(City, State)
on __________________________________
(Date of Brith)
Resident at ______________________________________________________________
(Permanent Address)
________________________________________________________________________
waive the Insurance Plan offered by CLCT and say:

I will purchase an insurance policy with any private insurance company in Taiwan that will
cover me for the same medical-hospitalization requirements, as specified by the Taiwan
government, without exception or limitation to the coverage I purchase.

That the above mentioned coverage will be for my entire stay in Taiwan and that I will be
responsible for any other expenses of this nature I may sustain while in Taiwan.

____________________________

_________________________________

Signature

Date

---------------------------------------------------------------------------------------------------------------------- To join the insurance plan, please make a check.

I am _______________I would like to join the insurance plan, please contact agent for me.

CLCTNKNU 2013. All rights reserved.

()

(
)

377

(1)/
(2)

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()
:

():

:_______________

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