APPLICATION FORM FOR SHORT-TERM SCHOLARSHIP FOR FOREIGN TEACHERS OF CHINESE LANGUAGE

Personal Data:
Agency No. Agency Name 00005 Asean University Network Family Name Given Name EFENDI CHANDRA Chinese Name Gender GUO YONG RAN (l8q6 Male Date of Birth Marital Status 1982-10-15 Married Nationality Native Language Passport No. Indonesia Indonesia language R 553856 Country of Birth City of Birth Religion INDONESIA PALEMBANG BUDHIST Permanent Contact Tel Permanent Contact Fax Permanent Contact E-mail +62-711-350967 guo.yongran@gmail.com Permanent Contact Address Dr.M. Isa Street Gg. Fajar No. 33A/1026 Palembang 30114 - Indonesia Present Contact Tel Present Contact Fax Present Contact E-mail +62-813-67701680 guo.yongran@gmail.com Present Contact Address Dr.M. Isa Street Gg. Fajar No. 33A/1026 Palembang 30114 - Indonesia

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Education Background and Employment Record:

Highest Diploma Institution Sriwijaya University Years Attended From 2000-10-23 To 2005-06-23 Certificates Obtained or to Obtain Barchelor Degree

Fields of Study Chemical Engineering

Other Certificate I Institution Guo Jia Han Ban (V[lIR-YVlIeY^ Years Attended Fields of Study From 2009-06-23 To 2009-06-27 Teacher of Chinese Training Program Certificates Obtained or to Obtain _____________________________________________________________________________________________________________________ Serial Number: 105679 Page 1 of 3 Generated: 30 Dec 2011

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% Supporting Documentation Attached(Please Indicate with 'X' in the Bracket.):

% Two Application Forms. % Two Letters of Recommendation. % Admission Letter or Admission Notice of Chinese Universities. % Transcripts of the Most Advanced Studies(Notarized Photocopy). % Diploma of the Most Advanced Studies(Notarized Photocopy): Bachelor's% Master's% Doctor's% Others% % Foreigner Physical Examination Form(Photocopy). % Study Plan in China. % Articles or Papers Written or Published. % Examples of Art(6 color pictures)and Music(1 audio tape)Work(Only for the applicants applying for Fine % Other Attachments(List Needed)_______________________________________________________ Note:Each Set of the complete materials should not exceed 20 pagesPlease use DIN A4. Whether the candidates are accepted or not,all the application materials will not be returned. % I Hereby Declare That:

1. All information and supporting documentation provided for this application are complete, true and corre 2. During my stay in China,I shall abide by the laws and decrees of the Chinese government,and will not p in China which are deemed to be adverse to the social order of China and are inappropriate to the cap 3. I will agree to the arrangements of my institution and specialty of study in China made by CSC,and will in these two fields without valid reasons. 4. During my study in China,I shall abide the rules and regulations of the host university,and concentrate o and follow the teaching programs arranged by the university. 5. I shall go through the procedures of the Annual Review of Chinese Govemment Scholarship Status as 6. I shall return to my home country as soon as l complete my scheduled program in China,and will no reasons. 7. If I am judged by the Chinese laws and decrees and the rules and regulations of the university as havin I will not lodge any appeal against the decision of CSC on suspending,or withdrawing my scholarship,o

Signature of the Applicant:_____________________Date:_________ (The application is invalid without the applicant's sig

_____________________________________________________________________________________________________________________ Serial Number: 105679 Page 3 of 3 Generated: 30 Dec 2011