国籍/Nationality

 护照号码/Passport No:

 婚否/Marital Status:

 出生日期： 年 月 日
Date of Birth:  Year  Month  Day

 出生地点/Place of Birth

 通讯地址/Mailing Address：

 电话和传真/ Tel & Fax:

 最后学历/Highest Academic Degree Obtained:

 职业/Occupation:

 工作和学习单位／Employer or School Affiliated:

 学习专业 /Field of Study in China:
 临床医学/Clinical Medical  □              针灸/Accupuncture  □                     汉语/Chinese Language  □
 口腔医学/Stomatology □                  儿科医学/ Pediatric Medicine □
 其它/Others                                                               

 学习专业期限： 自       年      月      至        年      月   
 Duration;        from     Yr      mo,     to        Yr      mo

 留学类别与计划：/Student Status and Plan in China
 学士学位/Bachelor’s Degree □                       硕士学位/Master’s Degree □
 博士学位/ Doctorate        □                       进修生/Advanced student  □
 访问学者/Visting Scholar   □                        短期培训/Short training  □

 推荐单位：/Reference:

 在华事务担保：人/Guarantor in China:

 备注：/Remarks

 填写日期：/Date

 本人签名：/Signature