2018 Taiwan Experience Education Program
Application Form
Date of application______(MM)/______(DD)/________(YYYY)
1. Please PRINT clearly in all capitals with black ink.
2. Complete all sections and send to Gary Pritchard: gpritchard@cerritos.edu
Personal Information
Full name as on the passport:
(Surname/Last name) (Given name/First name)
Full name in Chinese, if any:
Place of birth (city/country):
Date of birth: (MM)/ (DD)/ (YYYY) Sex:□ Male Female
Nationality: _____________________________ Passport No:
Full name of the school:
Major/department: ___________________________ Undergraduate Graduate GPA
Permanent address:
Mailing address:
Tel/Mobile: ______________________________ E-mail:
Special diet: Vegetarian Allergic to
How does this program fit within your academic goals? What do you hope to gain from this
experience? (200 words max)
Have you traveled abroad? If so,where?
Emergency Contact Info:
Name: _________________________________ Relation to the applicant:
Tel/Mobile:______________________________ E-mail:
Attach recent
photograph here
(about 1” x 2”)
Cerritos College
Taipei New Taipei City Tainan City
Fall Semester July 9 – August 10 June 1 – July