姓/Surname：

中文名字/Chinese Name

照片/Photo

名/Given name：

性别/Gender

国籍/Nationality

护照号码/Passport No.

有效期至/Valid Until:

民族/Religion

婚否/Marital Status

出生日期：            年            月            日

Date of   Birth：         Yr.           Mon.        Date

出生地/Place of Birth

电话号码Telephone

电子邮箱 Email Address

通信地址/ Address for correspondence   including postcode, contact person and telephone

汉语能力

Chinese Proficiency

很好/Excellent   (    ) 好/Good (    ) 较好/Fair (    ) 差/Poor (    ) 不会/None (    )

HSK证书     级     分   HSK Certificate, Level     Marks       

教育经历（从小学起）/Academic Background (From Primary School)

在校期间 (From/To)

学校 (Institutions)

所获学历（Diploma/Degree   Obtained）

本人工作经历/Employment   Record

起止时间 (From /To)

工作单位 (Employer)

职务及职称 (Posts Held)

申请人亲属情况/Family   Members of the Applicants

姓名/Name

职业/ Occupation

联系电话/Telephone

父亲/Father

母亲/Mother

配偶/Spouse

希望在8181801威尼斯学习的专业或专题/Specialty or Field of Study   in HPI

学生类别

Student Status

□  语言生                    □  本科生               □  普通进修生

Language   Students     Undergraduate       General   advanced   Student                    □  高级进修生

Senior   advanced Student

学习期限

Duration

自/from：年/Year        月/Month          至/to：年/Year          月/Month          

经费来源

Financial Support

团体资助/ Organization（   ） 家庭资助/ Family（   ） 个人支付/ Self-support（   ）

推荐单位信息/ Information for Reference

推荐单位/Organization   or Person

联系电话/Telephone

E-mail

在华事务担保人/ The   Guarantor in China

姓名/Name：

联系电话/Telephone：

职业/ Occupation：

联系地址/Address：

经济担保人或机构/Financial Guarantee

姓名/Name：

联系电话/Telephone：

职业/ Occupation：

联系地址/Address：

申请人保证/I hereby affirm that

1.上述各项中所提供的情况是真实无误的./All the   information I provided above is true and correct.

2.在校学习期间遵守中国政府的法规和学校的规章和制度./I   shall abide by the laws of the Chinese Government and the regulations of Henan University of Science & Technology.

3.接受8181801威尼斯的学习和生活安排./I shall   accept the arrangements of Henan Polytechnic Institute regarding to my study   and living.

日期/Date：                        申请人签字/Applicant’s signature：                               

★填表注意事项/Notice for filling the application form

1.上述所有信息均用电脑输入, 以免字迹不清延误审理时间./All   the information filled in the Application Form should be typed by   means of computer to avoid misunderstanding or mistakes.

2.在华事务担保人或机构, 须为在中国境内的人士或机构, 以便在紧急时能与其取得联系./The   guarantors charging your case in China, we will contact them for your case   when necessary.

3.申请人在递送本申请表的同时, 请提交/Please send the following documents with this form.

①护照复印件/One photocopy of   your passport

②最高学历证明/An official   certificate of your highest education (or notarized photocopy)

③学习成绩单/Official   transcripts (or notarized photocopy)

④经济担保或银行存款证明/ Financial guarantee   or bank statement

⑤无犯罪记录证明/Certificate   of Non-criminal Record

4.如果申请材料为非英语或非汉语版本, 需翻译为汉语或英文版本并经过权威部门公证./If your original certificate is not English or   Chinese version, please ask authorized department or your school to translate   it into English or Chinese.

5.若无申请人签字，视为无效申请./   The application is invalid without the applicant’s signature.