Application Form Page 1 of 4

Application Form (For U.S. Applicants)

A. PERSONAL INFORMATIONFirst Name Taiwanese name (if applicable)

Date of Birth (mm/dd/yyyy) Place of Birth - City, State Citizenship US Citizen US Permanent Resident

Country of Citizenship if not UScitizenEmail Address

@Gender

Male FemaleSocial Security Number

Permanent Address

Street City State Zip Code+4 CountryTelephone Number (Day) Telephone Number (Night)

Name of Parents (English & Taiwanese if applicable)

Father MotherEmergencyContact

Phone Relationship

B. EDUCATIONAL INFORMATION List Chronologically the five most recent educational institutions attended since high school.High School City State Year Graduated GPA (e.g. 3.0/4.0)

Name of School City State From (mm/yy)

to

GPA (e.g. 3.0/4.0)

College, University, Graduate and/or Professional School:

Name of School City State From (mm/yy)

to

GPA (e.g. 3.0/4.0)

Name of School City State From (mm/yy)

to

GPA (e.g. 3.0/4.0)

Best SAT/ACT Score:

Degree Received/Expected and Major(s)

Degree Received/Expected and Major(s)

/

/

/

/

M.I.

Mailing Address Good Through (mm/yyyy):

Street City State Zip Code +4 Country

Last Name

Graduate entrance exam, if applicable. Score:

Degree Received/Expected and Major(s)

Year Taken:

Type:

List significant scholastic honors, including scholarships, prizes honor societies, etc.

In an academic setting, have you been subject to disciplinary sanctions, or are charges pending? No Yes

Have you ever been expelled, suspended, placed on probation, or given an academic warning? No Yes

Have you ever been convicted of a felony? No YesExplanation for any "Yes" answers to the above:

C. LEADERSHIP AND EXTRACURRICULAR ACTIVITIES (check all applicable)

Business InternshipCommunity Volunteer

Issue Advocacy & AwarenessPolitical/ Government InternshipModel U.N./ Mock Congress Debate

List and describe relevant activities you have participated in the above. Include achievements, positions held, periods of involvement, and average hours per week ofparticipation. (Use separate sheet if necessary) List Taiwanese American activities in Section E.

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Other, please specify:

Non-Profit WorkJournalism/ Media

Student Body Leadership

D. TAIWANESE AMERICAN COMMUNITY ACTIVITIES (Fill in when applicablel. Please include dates and involvement)

Position/Responsibility

Hrs/Week Reason for leaving

Employer 2

Position/Responsibility

Hrs/WeekFrom mm/yy to mm/yy Reason for leaving

Employer 3

Position/Responsibility

City, State

From mm/yy to mm/yy Reason for leaving

Employer 4

Position/Responsibility

City, State

Hrs/WeekFrom mm/yy to mm/yy Reason for leaving

Employer 1

City, State

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Hrs/Week

F. EMPLOYMENT INFORMATIONWhere applicable, list the three most recent employments, including summer and/or part-time employment, internship and military services:

1. In your opinion, what is the greatest challenge facing Taiwan today?

2. As part of the solution to the above, what can you do to help?

E. WRITE-IN ANSWERS Please limit your answers to 150 words or less for each question.

City, State

From mm/yy to mm/yy

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H. CERTIFICATION:

I, the undersigned, hereby certify that all the information provided in this application is accurateand complete. I will promptly inform the Foundation in writing of any changes in any of the factsstated therein. I understand that providing any false, misleading, or incomplete information willresult in the rejection of my application or the revocation of my admission to the Program. Ifselected, I agree to abide by all Program rules.

Signature of Applicant Name of Applicant Date

Application package must include the following:1. Completed Application Form;2. A 500-word Personal Statement;3. Copy of most recent transcript4. Two (2) letters of recommendation;5. Any optional supplementary material to help the selection committee evaluate this application.

Submit 1 original set plus 4 duplicate sets of the above items to:

Formosa Foundation350 South Figueroa Street, Suite 275

Los Angeles, CA 90071

All material must be received on or before March 15, 2011. If sending via express mail (e.g., FedEx orUPS Next Day), designate "afternoon" delivery and waive signature requirement. To contact the FormosaFoundation, please call (213) 625-1991, or fax (213) 625-1941; Email: formosa@formosafoundation.org.

Position/Title Organization Phone number

Name Position/Title Organization Phone number

Name

Relationship to Applicant Email Address

Relationship to Applicant Email Address

G. TWO (2) REFERENCES List those who are not already writing letters of recommendation.

I. APPLICATION INSTRUCTIONS: