附件5：报名申请表（英文）.docx

Hanban-College Board Chinese Guest Teacher Program Application Form for Chinese Teachers Place an ‘X’ in the checkboxes if the information is TRUE. Family Name First Name English Name (If any) City/Province of Birth Gender Marital Status Male Female Date of Birth (M/D/Y) Single Married Divorced PROFESSIONAL BACKGROUND Current Position Elementary School teacher Junior Middle School teacher Senior Middle School teacher College teacher Teacher in other school, please specify Other Position, please specify Primary Duties School (Employer) Does your current school have a sister relationship with any K-12 U.S. schools? Yes, The U.S. sister school’s name, city and state is: No 1. Employer Period of Full-time Employment Level(s) Taught City, Province Start (M/Y): End (M/Y): Position Elementary Junior Middle Senior Middle College Subject(s) Taught Other, please specify List and describe duties 2. Employer Most Recent FullTime Work Experience Period of Full-time Employment Level(s) Taught City, Province Start (M/Y): End (M/Y): Position Elementary Junior Middle Senior Middle College Subject(s) Taught Other, please specify List and describe duties 3. Other Level(s) Previously Taught, if relevant Elementary Junior Middle Senior Middle College Other, please specify If you have additional teaching experience not covered here, please attach extra pages. If any of your listed work experience was not full-time, please attach additional explanation. EDUCATIONAL BACKGROUND School Name Start (M/Y): Dates Attended Educational Background (after high school) City, Province End (M/Y): 4-yr. Bachelor’s Master’s Other Degree Attained Major List education coursework School Name City, Province Start (M/Y): Dates Attended End (M/Y): 4-yr. Bachelor’s Master’s Other Degree Attained Major List education coursework If you have additional educational experience not covered here, please attach extra pages. CERTIFICATIONS Date Obtained: Certificate of Teacher Qualification Certificate of Teaching Chinese as Foreign Language Mandarin Level Type: College/University Secondary School Vocational School Other School, please explain: Yes Level: 1 A (Highest) Type: None None Date Obtained: Certificate of English Proficiency Level Primary School 1 B (Higher) 2 A (High) None College English Test (CET) Test for English Major (TEM) TOEFL Other IELTS Date Obtained: None Level/Score: Yes, obtained on: Valid Passport Yes, expires on: No Have you ever been outside of China? AWARDS Professional and/or Educational Awards Received ADDITIONAL SKILLS/INTERESTS Other Languages Other Skills and/or Interests you would like to share (music, sports, games, etc.) Driver’s License Yes No No If licensed, approximately how many driving hours per week? If yes, when, where, and for what purpose? PERSONAL STATEMENT Please describe why you want to teach Chinese language and culture to students in the United States and what strengths you will bring to the Guest Teacher Program. (Maximum 600 characters) PAST VISA RECORD Have you ever been refused any visa to the United States? Have you ever traveled to the U.S. on J-1 Teacher Visa? Yes Yes No No Unsure If unsure, please name the organization/program that sponsored you and the purpose of your stay. CONTACT INFORMATION School Address Postal Code Home Address Postal Code Work Phone Fax Number Home Phone Cell Phone Email Address Skype Name (if any) Emergency Contact Person Name: Phone number: Relationship: Address: FAMILY BACKGROUND Relationship Name Profession Place of work City Province Phone # Spouse Child Father Mother Brother(s) Sister(s) Do you have any family members and/or relatives in the United States? Yes. No. If yes, explain your relation to the person(s) and their immigration status: Employer Permission (with stamp) Provincial Education Department Permission (with stamp) By signing this form, I certify that all information provided above is true and complete to the best of my knowledge. I understand that if any of this information is found to be substantially inaccurate or incomplete, my application to this program will not be considered. Signature:_________________________ Date:______________________ NOTE: 1. Fill in all blanks with true information; 2. Attach extra pages if necessary.