附件2：罗氏诊断医学检验及生命科学教育基金申请表.doc

CONFIDENTIAL 保密信息Please fill in details carefully. 请仔细填写For Filing ONLY仅供存档使用 APPLICATION FORM 罗氏诊断医学检验及生命科学教育基金申请表Please attachyour recentpicture here.请附近期报名照PERSONAL DETAILS 个人资料Name (Chinese/English)姓名（中/英）:Gender 性别:Date of Birth 出生年月:Age 年龄:Social Outlook政治面貌:Source Place生源地: 省 市/县Nationality 国籍:Email电子邮件地址:Present Address 现在住址:Zip Code邮编:(Mobile/Pager移动电话/寻呼):ID 身份证号码:EDUCATIONAL BACKGROUND 教育背景University/College:(Undergraduate) Major:专业: From (YY/MM) To(YY/MM)自(年/月) 至(年/月) 今University/College:(Post-graduate)大学/学院名称(硕士研究生):Major:专业:From (YY/MM) To(YY/MM)自(年/月) 至(年/月)University/College:大学/学院名称(Doctoral博士研究生):Major:专业:From (YY/MM) To(YY/MM)自(年/月) 至(年/月)Academic Achievement(Undergraduate) 本科学术成绩Top 10% Top 30% Average Below AverageGPA 平均绩点(平均分)：Academic Achievement(Post-graduate) 硕士研究生学术成绩Top 10% Top 30% Average Below Average GPA 平均绩点(平均分)：Academic Achievement(Doctorial) 博士研究生学术成绩 Top 10% Top 30% Average Below AverageAcademic Achievement(Doctoral) EXTRA-CURRICULAR ACTIVITIES 校内外/社团活动Period时间Activities社团/活动Job Title职务Achievement/Award主要成就RESEARCH EXPERIENCE 研究经历Period时间Research Topic研究课题Job Title职务Research Achievement 研究成果INTERNSHIP & EXPERIENCE 实习和工作经历Period时间Company公司名称Job Title 职务Job Responsibilities 工作职责LANGUAGES & COMPUTER SKILLS语言能力和计算机能力English Level 英语水平 CET 4 CET 6 TEM 4 TEM 8 Other Languages 其它语言:MS Office 办公室软件 Excellent 精通 Good 良好 Average 一般 Poor 差Certificate/Rewards/Publications证书/奖励/发表论文Certificate/Time证书/时间Award/Time奖励/时间Publications/Time 论文发表/时间PERSONAL REFERENCE 个人背景情况证明人（社团活动证明人/老师）Name 姓名Occupation 职业Address 地址Telephone and Email 电话/电邮QUESTIONS 问题Describe three biggest achievements you have made in your college life. 你在大学期间取得的三个最大的成就。What qualities in you do you think have made you special? 你觉得你身上有什么品质使你脱颖而出？DECLARATION 申明I declare that the information given above is correct and complete to the best of my knowledge and belief. In the event of my application, I understand that false or misleading information given in my application may result in immediate withdrawal of the Scholarship and the honor. I further understand that the final confirmation of Scholarship is subject to reference check.本人保证以上所提供的资料信息完全属实，并认同如果本人提供任的信息有任何虚假或可导致公司判断失误之处，公司有权立即收回奖学金和取消荣誉。同时，本人理解公司是否给予本人奖学金的最后决定亦将取决于背景调查的结果。Signature of Applicant 申请人签字Date日期Roche Diagnostics China2Roche Diagnostics Scholarship Application Form罗氏诊断 中国地区罗氏诊断医学检验及生命科学教育基金-申请表