1
APPLICATION FORM FOR INTERNATIONAL STUDENTS TO STUDY AT NANJING COLLEGE OF
CHEMICAL TECHNOLOGY NCCT
. Please fill all the information requested. Handwriting is not acceptable. Please write None if not applicable.
Name
(as shown
on passport)
Last/Family Name Falah Arif Arafah
Photo Given Name Falah
In Chinese
! "
Nationality
Indonesia
# /Male %
&/Female %
'(/ Single %
)(/Marrie %
*+,-
!eligion
Islam
./01
"ate o# $irth
2 /ear !""# 3 /$on october
0/%ate &'
./4
Pla%e o# $irth
!5/Co&ntry Inonesia
67/City 'epara
89:;<=>?@A
Permanent (ress an )el* No*
!5/Co&ntry Indonesia 67/City (epara
BCDA/Postal Coe +,-./ 0 >?/)el* No* 1./2,233334,4
EF:;<=>?@A
C&rrent aress an )el* No*
!5/Co&ntry 67/City
BCDA/Postal Coe 0 >?/)el* No*
! #$%&' #()*+&'
Please sen mails to5 Permanent (ress C&rrent (ress
GH@A
Cell phone N&m6er
>IBJ
78mail
Falah)arif"'*+[Link] KLMN
9ighest 7&%ation
,ocational high school technic computer and
networ-
O@A
Passport No*
OP1
:ali &ntil
2/ear 3/$on 0/%ate
MQRN
Academic Information
STMUV
Name o# 9ome ;niversity
STWX
Ma<or at 9ome ;niversity
YM01
7ntran%e "ate (yyyy/mm/)
STZ[
N&m6er o# years enrolle at home &niversity
\]^_
.hinese language
proficienc+
\]MQZ[`a bc3
a bMonths o# Chinese St&y
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$an o# 9S=a)est o# Chinese Pro#i%ien%yb`a bGrae
or other %erti#i%ates whi%h %an show yo&r Chinese pro#i%ien%y
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/* Listening
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lNone % mn$asi% %opIntermeiate %qrFl&ent %
,-Categories of international st!ents"
st/ eA%hange st&ent % ]u/Lang&age st&ent %
vw/short time training st&ent % Wx/'&nior %ollege st&ent % yx/;nergra&ate %
z{B|})his appli%ation #orm has to 6e maile to`
<`~7625 @ XM!+ BCDA`210048
( ` International Education Institute, Nanjing College of Chemical Technology, No.625
Geguan Road, uhe !istrict, Nanjing "iangsu, China, 2#$$%&
)el5 12.8/+8+2?4322.12.8/+8+2?+133. 78mail5 <sn<hyg<yBgmail*%om
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)el*/Cell No*
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Pro#i%ien%y in Dther Foreign
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5nglish }Z[
"ate o# (rrival
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5mergenc+ .ontact 6famil+7
relati8es7 friends7 etc.9
.ontact ! 6in home countr+9
Name5 Shohi6&l (rois !elationship5 6rother
(ress5 )roso0 Pe%angaan0 'epara0 Central 'ava0
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Mo6ile phone5 1./2/1?..-.,1,
.ontact & 6in .hina9
Name5 !elationship5
(ress5 Mo6ile phone5
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!MQ1[-!MU!lyMQ
I here6y a##irm that5
1* (ll the in#ormation in this #orm is tr&e an %orre%tE
/* I shall a6ie 6y the laws o# China an the reg&lations o# the S%hool0 an will not parti%ipate in any a%tivities 0whi%h are eeme to 6e averse
to the so%ial orer in China an are inappropriate to the %apa%ity as a st&ent*
01` 2 3 0 `
"ate5 $ % (ppli%antFs Signat&re
`yZs !emar>s5 )he appli%ant is reG&ire to s&6mit5
1*OJ 1* photo%opy o# passport
/*KLMNJ /* photo%opy o# highest e&%ation %erti#i%ate
?* ?* $oy %he%> %erti#i%ate
-*MQRNJ -* photo%opy o# a%aemi% an wor> eAperien%e %erti#i%ate
./0
,iews of International 5ducation
Institute
12/Signat&re5 HHHHHHHHHHHHH 34/"ate HHHHHHH5/Cear HHHHHH6/Month HHHHH3/"ay
789/0
,iews of the principal
of the college
12/Signat&re5 HHHHHHHHHHHHH 34/"ate HHHHHHH5/Cear HHHHHH6/Month HHHHH3/"ay
z{B|})his appli%ation #orm has to 6e maile to`
<`~7625 @ XM!+ BCDA`210048
( ` International Education Institute, Nanjing College of Chemical Technology, No.625
Geguan Road, uhe !istrict, Nanjing "iangsu, China, 2#$$%&
)el5 12.8/+8+2?4322.12.8/+8+2?+133. 78mail5 <sn<hyg<yBgmail*%om