Application Form

ASEAN Leaders Fostering Program 2013/2014

I. PERSONAL INFORMATION
Name (as stated on the passport)
_____________________________________________________________________
FIRST NAME

LAST NAME

Citizenship (Nationality)_______________________
Date of Birth _________________________

Age ________ Sex: M / F

Religion____________
Passport Number ____________________ Place of Issue______________________
Issued Date____________________

Expired Date ______________________

Permanent Address ____________________________________________________

____________________________________________________________________
Telephone: (_____)_______________________Fax(_____)____________________
Mobile Phone: (______)________________________________________________
Present Address (If different) ___________________________________________
_____________________________________________________________________
Telephone: (_____)_______________________Fax(_____)_____________________
Email

______________________________________________________________

Please attach your resume

II. Educational Background

Faculty/Department_____________________________________________________
Major___________________________School Year___________________________
University ___________________________________________________________
University Address_____________________________________________________
_____________________________________________________________________
Telephone (______)_______________________Fax: (______)__________________
Grade Point Average ____________/___________ ex) 3.8/4.0
*Please provide your original maximum and earned GPAS and transformed ones on 4.0scale

2. Level of Language Ability (please circle one)

English: Poor,
fair,
good,
( If you have the Proficiency Test Result,
Name of the test :
Score:

excellent

Korean: Poor,
fair,
good,
( If you have the Proficiency Test Result,
Name of the test :
Score:

excellent

Other Language (please specify, if any)_______________________________

( If you have the Proficiency Test Result,
Name of the test :
Score:

3. Identify any exchanged programs you have attended over last 5 years;
3.1 Name of the Program_________________________________________
Country____________________________ Duration______________________
Name of the University or Institution__________________________________
Field of Study ____________________________________________________
Name of the organizer______________________________________________
3.2 Name of the Program_________________________________________
Country____________________________ Duration______________________
Name of the University or Institution__________________________________
Field of Study ____________________________________________________
Name of the organizer______________________________________________
3.3 Name of the Program_________________________________________
Country____________________________ Duration _____________________
Name of the University or Institution__________________________________
Field of Study ____________________________________________________
Name of the organizer______________________________________________

4. Identify any awards you have received;

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
5. Identify any activities you have done for your University;
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

III. STATEMENT OF INTENT

* If necessary, you can use separate pages to provide following information

1) Areas of Interest (Please indicate below the area(s) of study in which you are
interested to enroll during your stay at Daejeon University):

2) Goals and Objectives (What do you hope to accomplish through this program?):

IV. ESSAY
In the era of globalization, where borders are getting less relevant, how can we prevent
Transnational Crimes without compromising the smooth people mobility?

Please submit on a separate paper with no more than 1,000 words.

V. OTHER NECESSARY DOCUMENTS

PLEASE SUBMIT THE FOLLOWING DOCUMENT TOGETHER WITH YOUR
APPLICATION (your application will not be considered without the following
materials):
A.
B.
C.
D.
E.
F.

*A STATEMENT OF INTENT TO RETURN

(Certified by your university)
COMPLETED MEDICAL QUESTIONNAIRE
AN ORIGINAL TRANSCRIPT (in ENGLISH)
RESUME OR BRIEF BIODATA
TWO ADDITIONAL PHOTOS (3545mm)
LANGUAGE PROFICIENCY TEST RESULT (Optional)

. REFERENCE
3

Please provide us with comments on the applicants strength, weakness or personal qualities which you
believe would be helpful in considering the applicants application for this program.

Please provide the name of your recommender.

Name: _____________________________________________________________
Position: ____________________________________________________________
Address_____________________________________________________________
Telephone: _________________________ Fax: ____________________________

I, the undersigned, hereby acknowledge, under the penalty of perjury, that the foregoing
information is true and correct to the best of my knowledge.
Applicant Signature

Dated

__________________________

____________________________

Authorized Person Signature

Dated

(Preferable Director of International Relation Office)

__________________________

____________________________

Position ____________________
************************

MEDICAL QUESTIONNAIRE

Name of Applicant:
Age:

Sex (M / F)

Height:

Weight:

1) If the applicant has had a history of illness or other disorders during the last 5 years, please
describe treatment and present status.
2) List any abnormalities indicated in the chest X-ray.

3) What is the applicant's normal blood pressure?

4) Is the applicant free from infectious disease (AIDS, tuberculosis, trachoma, skin disease,
etc.)?
5) Is the applicant able physically and mentally to carry on intensive training away from his/her
home?

6) Describe the applicant's overall health condition (include remarks of the examining
physician).

7) Name and Address of the Clinic/ Hospital________________________________________

__________________________________________________________________________
__________________________________________________________________________
Date____________________________
Name of Physician: ___________________________________
Signature:______________________________________

Date__________________________ Signature of Application:___________________________