National Chiao Tung University 3 Application Form for International Degree Students Fall(1) 2017 iE ‘Application No. ] | 106A013M1IC1 PERSONAL INFORMATION Please provide your name as stated on your passport or national ID Previous family name (if any): Chinese Name: (fa Date of Birth: Jun/18/1992 (Mc (Ds i i ee) Gender: C] Female lll Male Country of Birth: Nationality: Sudan ARC Nofif any): DC00521537 Expiry Date: (Month)/(Day)/(Year) Passport No(if any) ‘Mother Tongue: Dinka ,Sudanese local dialects | Marital Status: Ill Single 0 Married 1] Other Te .886-974-103259 iG E-mail: bolwol@rocketmail.com | Mobite: Permanent Address: No. 1, Daxue Rd, East District, Tainan City, 701 Tainan City, taiwan Taiwan Mailing Address (if different), valid until _(mmiddlyyyyy': . 10/25/2010 No. 1, Daxue Rd, East Distiet, Taina City, 701 Tainan | PostaliZip Code: +806 | Postal/Zip Code: +886 | Father's Name: Wol Ayii Father's Country of Birth: Sudan Fathor’s Nationality: Sudan | Remiere i toes 27s ‘Mother’s Name: Ajok Mayen Mother Country of Birth: Sudan Mother's Nationality: Sudan Emergency Contact: Name: Wol Ayii Relationship: Father Tel: +211-955-364626 Mobile: Em: 2ac728@gmail. com |Contact in Twan any: Name: Chen, Shih-Hsiung Tel: +886-623-89940 Mobile: Email: shchen86@hotmail.com : GuardiansProgram of Study Priority | College & Department/institute Degree Program 4 _ | Intemational College of Semiconductor Technology Graduate Program of - Intemational College of Semiconductor Technology =e 2 _| Intemational Programs EECS Int! Graduate Program Master's College of Engineering Dept. of Mechanical Engineering Micro/Nano 3 | Engineering Group Master's EDUCATION BACKGROUND Highest Level of eerie Degree: Bachelor Name of Institution: National Cheng Kung University,NCKU | [Location of institution: Tainan City Taiwan (City, State) Taiwan (Country) Graduation Certificate: WW Expected / C] Obtained in ! (mmiyyyy) Period of Study Program | Grade Average ral Bs | . Energy Engineering( Intemational Bachelor 491 2018 = 6) 2017 Te Oa eae every) 284 outof 43 ‘Thesis/Project Topic: Catalytic Pyrolysis of biomass and eficient use of treadmill to produce energy for workout. | Solar power | generation, Semiconductor | eee, 4 Chen-Wei shin and Wei- | Field of ‘Electric power | | ThesisiProject Advisor | isiang lai Interest system and Renewable | | energy areas like bio - | ‘energy, solar thermal et. Other Education : Information ooree Name of Institution: 2. | Location of Institution: Period of Study Program {0 : 1 | Secondary Education Name of Institution: Stena Hill School | Location of institution: Kampala Uganda (City, State) Uganda (Country) al Grade Period of Study | Diploma | Aone 7 t 21 2010 - 10 / 2011 | C1 Expected / Ml Obtained in 11 / 2012 (mmiyyyy)|3.24 Ut 4.0 SCHOLARSHIP STATUS. ‘A. Taiwan Scholarships Status: (Apply through overseas Tai Offices) C1 I have been awarded Taiwan Scholarship. C1 | am applying for Taiwan Scholarship. Ill | do not intend to apply. _ ee |B. Application for NCTU Scholarships for Newly Admitted Students: Ml Yes, please consider my eligibility. (No additional application form required) C] No, | do not intend toC. Application for other scholarship: (For scholai respective organizations) O other: ship not listed above, please apply via the LANGUAGE PROFICIENCY Have you ever learned _ Hearts 1 Yes 1 No Il | am a native speaker. Ityes, for Where did you learn how long? English? Have you ever learned Chinese? Yes (No Ifyes, for | 1Year3_ | Where did you learn | Chinese language center ,college of liberals howlong? | Month | Chinese? arts, National cheng kung university Pei denea Reading | Writing Ustoning ‘Speaking Chinese [Poor [Poor | Good | Good English Excalient | Excellent | Excellent | Good Specify if you have taken any Chinese or English proficiency test(s). (Attach copies of results.) Language — Name of Test Score | Date Chinese | [Engish | SPECIAL HEALTH CONDITIONS (Attach a valid health examination result with the application) Do you have any special health condition Yes ll No Ifyes, please specify: section) WORK EXPERIENCE (required for GMBA applicants; other applicants are also encouraged to complete ‘Company Name Company Tel | Supervisor's Name Company Name T Duration of Service | Supervisor's Email Address Position Held ‘Company Tel Supervisor's Name Duration of Service Supervisor's Email Company Name Address. Position Held Company Tel Duration of Service | | Supervisor's Name | Supervisor's EmailACADEMIC HONOURS & EXTRACURRICULAR ACTIVITIES (optional) Period (mmiyyyy - mmiyyyy) __| Details DECLARATION & AUTHORIZATION |, the undersigned, hereby certify that all the following statements and representations are true and correc. |. Lam qualified to apply as an intemational student as per the ‘MOE Regulations Regarding Intemational ‘Students Undertaking Studies in Taiwan’ released by the Ministry of Education, R.0.C. (Taiwan), | Ihave carefully read the important information and application instruction and I fully understood my obligations as an applicant. IIL. The highestevel diploma submitted by me (for the undergraduate applicant: a high school diploma; for the graduate school applicant: an undergraduate degree certificate or master’s degree certificate) is a genuine and valid legal document in the country where the schoo! is located and is comparative to the ‘one offered in the R.O.C. (Taiwan). IV. | fully understand that an applicant submitting forged, fabricated, or altered papers for the application of NCTU Intemational degree students shall be subject to enrollment qualification cancellation; or a of enrollment and denial to the request of any certificate pertaining to study (Please refer to of "MOE Regulations Regarding Intemational Students Undertaking Studies in Taiwan’). | authorize National Chiao Tung University (NCTU) to verify the truthfulness of any of the above statements ‘or representations. | have no objections in accepting the consequence if my admission or registration of my student status is revoked in the event of any falseness or misrepresentation. | understand that failure to ‘comply with the above mentioned regulation from the Ministry of Education of R.O.C. (Taiwan) will result in either cancelation or revocation of admission offer, student status or degree certificate. Violators will not | receive any academic documents, STATEMENT OF UNDERSTANDING |, the undersigned, hereby confirm that | am applying to National Chiao Tung University (NCTU) as an Intemational degree students. | am aware that the estimated expenses are around US$6,000 per year, including tuition, fees, insurance, books, facilities, housing, etc. (actual costs varies). | fully assume the responsibilty to finance my study and stay at NCTU. If am admitted to NCTU with a scholarship, | agree ‘to comply with respective scholarship regulations and continue to pay for relevant expenses whether | remain a scholarship recipient throughout my entire period of study or not Applicant Name: Madut Bol Wol Ayii Applicant Signature: Date: 10 Montw 9.9 Day! 05 Year