2016

2016 Application Form for ROC (Taiwan) Ministry of Education

Huayu Enrichment Scholarship
INSTRUCTIONS:
This application form should be typed and completed by the applicant. Each question must be answered
clearly and completely. Detailed answers are required in order to make the most appropriate arrangements.
If necessary, additional pages of the same size may be attached .

1. PERSONAL DATA
a.NAME

Title Mr.
SurnameLast namePrasetyo
Given Name(s) Dimas Budi
Chinese Name

b. CITY and
COUNTRY OF
BIRTH

c. NATIONALITY

d. CONTACT
INFORMATION

Please attach a
photograph that has been
taken within the last 3
months.

Nganjuk, Indonesia

*Note: If you are an overseas Chinese student, or hold a valid R.O.C.

passport, you are not eligible to apply.

Indonesian
Permanent AddressJl. Kwijenan I//4, Jombang, Indonesia
Mailing Address (If different from above) Jl. Danau Paniai VII H4 C21,
Malang, Indonesia 65138
Telephone+62 341 715908

E-mailmdimasbprasetyo@gmail.com

Cell phone: +62 81233344100

e. SEX
f. MARITAL STATUS

g. DATE OF BIRTH

Male
Single

Female
Married

(DayMonth Year ): 05/12/1990

h. PAST
RESIDENCE in
TAIWAN

i. Taiwan
Scholarship/
Huayu Enrichment
Scholarship Award
History/

j. HEALTH
CONDITION

Never ;

Yes, from

None ;

Yes, from

(dd/mm/yr) to
(dd/mm/yr);;
reason for staying in Taiwan:

(dd/mm/yr) to

(dd/mm/yr);

Type(s) of Scholarship Awarded:

Excellent

Good Fair

k. ANY CHRONIC
DISEASES

None

YesPlease specify

l. CONTACT
PERSON, IN
CASE OF AN
EMERGENCY

Name:

Relationship : Fiancee

Address: 8042470
E-mail : imeevip@gmail.com

Tel: +886 9744 1944

2. LANGUAGE PROFICIENCY
LANGUAGE
PROFICIENCY

ENGLISH
CHINESE
INDONESIAN

COMPREHENSIO
N
Excelle
Good Fair
nt

READING
Excellent

Fair

Good

WRITING
Excelle
nt

Fair

Good

SPEAKING
Excellent

Fair

Good

3. EDUCATIONAL BACKGROUND
Level
Secondary
Education
Undergraduate Level Education

Name of Institution

Country/City

Period of Enrollment

SMA Negeri 2

Indonesia/
Jombang

2006 2009

University of
Brawijaya

Indonesia/
Malang

2009 2014

Graduate Level Education

4. REFERENCES ()
Position

Phone, E-Mail or Mailing Address

Head of Department of Electrical

Engineering, University of Brawijaya

Jl. M.T. Haryono 167 Malang

65145
Phone: +62 341 554166
Jl. Yos Sudarso, Osmo-Tenau,
Kupang 85351
Phone: +62 380 8563004

Name

M. Aziz Muslim,
S.T., M.T., Ph.D.
Rommy D. Putra

Manager of Department of
Maintenance, PT. Sarana Agra
Gemilang KSO PT. Semen Kupang
(Persero)

5. PREVIOUS EMPLOYMENT (Use one line for each position)

Position

Company/Organization

Period of Employment

Responsibilities

6. PRESENT EMPLOYMENT
a. COMPANY/

PT. Sarana Agra Gemilang KSO PT. Semen Kupang (Persero)

ORGANIZATION

b. POSITION
d. CONTACT
INFORMATION

Electrical Planner of
Department of Maintenance

c. From
October 2014 - Now

Address Jl. Yos Sudarso, Osmo-Tenau, Kupang 85351

Tel +62 380 8563004

Cell phone:

Fax +62 380 890094

E-mail

e. TYPE OF ORGANIZATION

Govt. Ministry/ University/

Institution

Locally-owned

Govt./State-owned Agency
Enterprise

Joint Venture Foreign-owned

NGO Enterprise
7. LANGUAGE CENTER WHERE YOU PLAN TO ATTEND IN TAIWAN
University-affiliated language center:

Chinese Language Center - National Sun Yat-sen University

8. BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN

I am highly interested to study Mandarin Chinese in Taiwan. The first Taiwanese people that I ever met,
had left me a very good impression of this country. He is Mr. Marco, an engineer from Tai & Chyun
Associates Industries, Inc. I was working with him for a project in my current company. I adore his
hard working attitude and humbleness. It was a really pleasant experience for me to work with Taiwan
people and I am eager to have more experiences with even more amazing people in Taiwan. In addition
to that, I am also planning to continue study in National Sun Yat-sen University, together with my
fiance who will be a doctoral student in the campus. I have heard many good things about the school
and I am sure the Chinese Language Center of NSYSU is the best place to learn Mandarin Chinese and
meet great Taiwan people.
I have applied and accepted to the Chinese Language Center of NSYSU. I am planning to take two
three-months courses from September November 2016 and December 2016 February 2017. As I am
still a beginner in Mandarin Chinese, I will learn introduction of Mandarin phonetic symbols and basic
practical conversation. I am also eager to take additional classes that are offered by Chinese Language
Center of NSYSU, such as the origin of Chinese characters and Chinese calligraphy. I believe these
courses will help me to acquire better command of Mandarin Chinese, and hence greater understanding
and appreciation of Taiwan's culture, as the goal of Huayu Enrichment Scholarship program..
4

9. DECLARATION:
I declare that: The information I have given on this application is complete and accurate to the best of my knowledge.
Applicants Signature

Date

_____ /_____/_____