THE AMERICAN CHAMBER OF COMMERCE IN THAILAND · PDF fileTHE AMERICAN CHAMBER OF COMMERCE IN...

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AMCHAM THAILAND THE AMERICAN CHAMBER OF COMMERCE IN THAILAND \'I£> Ylff 1 r1t1 71h floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330 Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected] 2560 1jPage

Transcript of THE AMERICAN CHAMBER OF COMMERCE IN THAILAND · PDF fileTHE AMERICAN CHAMBER OF COMMERCE IN...

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AMCHAM THAILAND

THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

\'I£> nT~f-11ma.i~n'Mi1"Mi1h::L Ylff 1 r1t1

71h floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected]

2560

1jPage

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~-THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

'Mem1A'1ma.i'in"1"1h::mAlm.1

7th floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected] AMCHAM TH;\Jlt\ND

THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

'M em1A'1ma.i'in"114th::L nA l n EJ

7th floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

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' , . . .

THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

MBTITtA'lB La.i1n" '"1h::merlnt1 mJ-AMCHAM THAil.AND

71t1 floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini , Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected]

AMCHAM Scholarship Application Form

"" 'JJEl - \41l.lff~l'I (\41[J/\41\lff11) .......................... ...... .. .... .............. ... ........................... .... ....... .... .... .. ... ...... .. .. ................. .

Name - Surname (Mr. I Miss) ....................................... ............ ............................ ....... .... ......... ............... ... .. ............. .

"" ' 'llElLl'l\4 (NickName) ... .... .... ... .... ..... .... .

1l4L~El\4ULn~ (Date of birth) .... ......... ... El1 ~ (Age) .... ............ ffil!'ll1~ (Nationality) ..... ... ................ ..... ..... .

.. I .. .,, ._., ti nauona.in::L1Jll\UJ'lW1J9'1' 1'::!1''111'" (Address on Thal National ID Card) • Ll'l'llfl (No) ............... ....... v.~il (Moo) ........ 'llElU (Soi) .................................... tl\4\4 (Road) ................. .. ..... .... .. .... .

~11Jl'I (Tambol) .............. ......... ......... ..... ~1L11El (Amphur) ....... ..... .. ............. .

i'3Vi1fl (Province) .. ...... .. .................. .......... .. ... \1. 1 ... .. t ... .. 'lViffLu'llituU (Postcode) .. .... .. ... ..... .. .. Yl'lf'l'VO'I (Telephone) ............. : ....... .. ..

.i '.'I' ... .I... I 1 ... nauun1J"f19'~9'B ~ (Current Address) . ' (mm1Please~) U1\4U~1l.11'l~1Parents Home D I ViElvinDormitory D I qJ1~r1uEJ\IRelatives D I 5\4']

1

Other D (lu'lm::m1m~::LBUfl please specify) ..... ....... ...... .......... ............... .............. ................... ...... ............ . 1

Ll'l'!l.yj (No) .. .... ..... .. .... ... .. v.~il (Moo) ...... .. 'llElU (Soi) .................. .... .. .. ..... ..... tl\4\4 (Road) ....... .. ... .... .... ....... ...... ..

~11Jl'I (Tambol) ... .................................. ~1 L11 El (Amphur) ..... ..... ..... ... .. ...... . . ... ... ... \'1.1 ... .. ) -;J\IV.1~ (Province) .. ... .... ................ .... ... ........ 'lViff Lu'llituU (Postcode ... .. ..... ....... .. .

lri'lfl'V'lli'UEJTIEJ (Mobile Phone) ........... ..... ... ... ... Email Address ..... .. .. ... ...................... .. .. .... .. ......... .... .. .................... .

B ~nu1 (Current and Previous Education)

"" ... ... 'l1Ell.IV.11fl[J1t'l[J ...... ............ .............. ... .. ... .. .. ........... ........................... ....... ........ ... .. ........ ....... ... ... ..... .. ... .. ........... .

Name of University ................................ .... ..... .... .... .......... .. .. .... ..... ...... ....... .. .. .... .... ........ .... .. ... ... ..... ... .... ........... ... ... . .

fltu:: .. ........... .. ........... .. ....... ... ... ....... .......... .. ..... .. .. ... ... Faculty .... ..... ............................................................. ............ .

1'111LEJn ....... ................ .. .......... ..... ..... .................. ..... .. Major ........... ... ... . ... .. ... ... .. .......... ... . ... ..... ......... ....... ..

'li'w1tnflnli1 (Student ID) ....... ... ... ........ ....... .. ... .. ..... .... ...... ....... ...... ...... .. ... .. .............. ....... ............ .. ....... .... ......... ... ... .

• ... .. :: !"! ..1 f d . A t h' ) ma.;if'lnli1'll\4ufl (Year o stu y commencing ugus t ts year .. .. .... ... ... .... ............... ...... ...................................... .

3 I r-' -' d ,,

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~-THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

M0017A10LaJ~n"1"1.h::Lt1flflt1EJ

AMCHAM THA ILAND

7th floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: O -2251-1605. Email: [email protected]

~1'U1'UUn1'lfln1'-1 (Length of course) 3 years D 4 years D 5 years D 6 years D

mfli1-;i::li1L1-;im1flni;.11-ui1 (Expected course completion date) ..... .. .... ................................. ................. .. ... .......... .

1::iunTiAn!t-1 110 nmuwi,nd'" fl m::/ft1t111211 iJfil'f1LfQ A::LL ·w1.mi.iu

Educational Level School Name/ Province Faculty I Major Graduation Date (GPAX)

... .. lJ 1i ll ll fl 'U

(Middle school)

tl"irt.1ll1hnu

(High school)

u1::n1fri1vu~11 .. ,;.,,(l11nij)

(Vocational Degree - if any) ... ... ..

ll~11'YJ[J1~ll (~1nLfltJL'lll'U

.I.I 'Yltl'U) (University - if any)

_., ... ..t • ... ... ~ ... .. l I D l I D" I .. 1JQQ1J"""1ih'11Jfl"n11ftn!f-1()" t'l\111() II II/ L21, n1m11::1JTIUft::LDU"

' ' J ' '

Are you currently receiving any scholarships D No I D Yes, please provide details

il~LflU 1R'i'u'l"n11An!t-1~'K, n"A'n1 I fttnu'K / ~flflft iln~uft'K'Km1t~n'K ,J1wl'Klil • • From/To Organization/ Institution/ Other sponsor (Please give detalls) Amount I year

'I .. l"" ~ ... ·1·01· n<I• .. L"()"flLflU "11Jfl'Kn17t'ln!f-1 O'K., 'M1D II 11 / L.J L21, n1m11::1JTIUft::LDUit • J ' '

Have you ever received any scholarships D No I D Yes, please provide details

n..a l "" a ~ flLflU it11J'l"n11 n!f-10'6 -.J .. ... .I ... , ..,

D"flm I ftn1u" / 1Jflflft flft'K1Jll'K"n11 'Mfl" ,J1wl'Klil • • • From/To Organization/ Institution/ Other sponsor (Please give details) Amount I year

4 I P a II,,

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·. '.

E- THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

MD011A1DLIJ~OMitM.1h::Ln«lnt1

AMCHAM n M JLA ND 7

1h floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605.Email:[email protected]

(Activities I Community Service)

21E E'1ffm U/L1n1 .. "' onu1uunu1nun::M"1n un01·nhL\nw1" Name of Organization When Describe Your Role Hlghllght the results of your activities

tYflTUm'l'ttnnn'llv~iifl1m1f!1 (Parents Marital Status)

D outr1un" (Live together) .. D MU111'1 (Divorced) D ut1nn"Eu (Separated) .. t~fomnn!tJn'\llJ~1lJm·n~lJ\l1nlm (How are you supported?)

D Ut'1·aJ11tl1 (Parents) D ut11 (Father) I D IJ11tl1 (Mother)

D utlnA10'1 (Guardian) .. D ~il11tlm1tf!m ~" ') 1t1!11llfttLiilltt (Other· Provide details)

Eiit11 Father's Name

utlnA1E'1 (or) Guardian's Name ..

V'1ilii~vrn~

Alive

D

01ll • Deceased Age

D

LU 011 fl1~ttfi il

Phone No.

51 j:' J J ...

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' ..

AMCHAM TH/\ JLANO

THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

Milfl1,.A1ELIJ~n"1"1.h::mAlm1

71t1 floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605.Email:[email protected]

~ .. ... .... _. Father or Guardian's Occupation E111YHJiJ'11J1i111M1'iHlunf'l,.iJ'1

.... \61ll;)1\I

Employer

-.., . ' tJ"J!t'1M1EE'1fln'1UJn!S\6

Company D iJtJ1ftM7EiJ1ft1Mn;i

Government /State Enterprise 0 E1gYIDft1::

Self Employed 0 .. Ln!tlllll

Retired 0 I

11\1\11\6

Unemployed 0

tiea111t111 Mother's Name

.. .... ~

EtJ"J!tfl/E\lflfl"J

Company Name I

Organization

E1ll • Age

.. l ..... 11 ll ft/Lfl E\6

Position Income/Month

J\liig191il~ Lftll

Alive Deceased

D 0 ... ....

Mother or Guardian's Occupation E1Wt't!IE'11J11'1i111M1'il~tlnf't,.E'1 ...

\61ll;)1'1

Employer

tJ;VnM7EE\lfi'n-niln!S\6

Company

fJtJ1ftM1E1J1ft1Mn"

Government/State Enterprise

E1gYID&'f"J::

Self Employed .. Ln»llm

Retired

-l1\l.i1" ,.10 Lfi1'uliu1"

Unemployed or Housewife

D

0

0

D

D

~eu;vn/0'1A°n1 Company Name I

Organization

'.. ' ., .

0 I

911LLM\6'1

Position Income/Month

~ '::· · ..

·' \ ~

11ll lt11E\6 'J Mal1llLMf!

Other Income Comments

I year

LtJ 011 n1it11fi il

Phone No.

Other Income

I year

Comments

6 I D.

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~-THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

'1enTifi,ma.i'in" t,uh::mAlm.1

7th floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected] AMCHAM THAILAND

.., 1fil

Name

£nu • il,;M ftm"ffm!n/ftm"i\ri1","

Age Occupation School/University/Work place

ftn1MU," t\,;'ne'lffU m nihhL"1!.lil\1'4nffn», (Picture of Applicant's House) u

. ~ ""' ....

L 'V\lbrn"lJ'Yl1J1'U

(Photo of family home. Show full

house)

'f1t1 l.ftio1Ro"

Monthly Income

71 p ,: ' . .' ·'

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THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

Moni'JA'10LaJ~n"1~nh::m«lnu

AMCHAM TH r\JLAND 7rh floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini, Pathumwan, Bangkok 10330

Tel : 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected]

1J~~U'4-ii1"r'iLi1 lfi-iiJL~'4ti11i'11 [J my current stipend/allowance ....

lilD"ft:: 1J1f1 ;nn (From)

(Monthly Allowance) A 'f o u A i11utl n li'l'JD'1 .... ., ... ., .. tJ .. 1'1J';J1'1 nu«. M'JDUIJO n1'J::"lm .. . Family or Guardian Employment Student Loan

.. o" "J ('f::u)

Tt11tt'J::1'1'h1i~1u1"LLotft::Liio" (Please Provide Details of Monthly Expenses)

fi1~1'n1fi1'1'11•h lw (Rent & Utllltles I

Month)

I l' - I A1"111Wft1 TAu111,-

fi101\t1,.

(Food/month)

Phone &

(Other

Personal

Expenses/Mo (Transportatl

on I Month) Internet I month nth)

In your own words, provide a 1-page personal statement on:

a) Why you wish to apply for this scholarship?

fi1l11ii'1tUJflnlti-i'l.J'Yl\4? •

• Other (specify)

fi1,a1,im4/tt1 ij,,.,,,

• I ...

M1D,-,-ll,"Ull

ROl'1011

(Tuition &

other fees I

semester)

tt1\tiWioua::

~t.Jn,-nt

tiomoa.1

(Books &

supplies I

semester)

b) What academic and personal achievements make you a suitable candidate to receive this scholarship?

m111tt1L1-;i i1'" iin nT1V11tiR1'49l11flu1'1rlfi11 ill'n L;!.J'4fifl11R11m1-;i:"lfii'u'l'"?

c) How do you think you will benefit in terms of career and personal development from obtaining this

Scholarship?

1 ..... .... - ..... , ... ..1 ...... A I 'VI....... .. ~,k r-1 atb: tJ"lr\4fl1\4fl1'l"r'i~\4191\4Lth1 LLfl :1"111 tl1"lr"r'ifl1\4Lfl1J1'1'Yl\4fl L, tJ\4fl m1-;i: Lfl'l1J-;J1 fl'Yl\4 mi fin lfl f11'1\4? •

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THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

Mom1R'1mJJ~n"1"1h::mRlfrn

AMCHAM TH /\JL 1\ ND 71t1 floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumpini , Pathumwan, Bangkok 10330

Tel : 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email: [email protected]

~ ~ 0 I '- ~ .f TJ1YH;t1TJil'41ft-1LOnft11tl1::no11n11ftJJR1'l"MDfl11A10LJJ~nwJ !Jl1ll'4 Required documents

D 'h.JRJJflnJDi'umnrnm1i1DuJin"lt.u.h::Lflfflm1 • D 1rn7u..im1ii 1 ~ir1ni::~11li tl1iii'1iimf..i 3 i'1ii!l (~u1~ 4)

D WiL "1umtl1::\i1il1tl1::111"11" ua:: Wi L "1Utl11!nHnli1vfi'!lllL'l1m.U"i'u1E1..iW1L "1,,!l..i~wiJm - .. D WiL "1~L'I m1L 7u ",, El.J'Yl nm fl m1flnli1\11n ffCl1\4flnWl tl;~u" lfl u tu LLfftl.J~L'I m1L 7u"\J::i !l.J li m1i'u1D..i

\11nii~1iflu1am t11if" (~1n~HJJfl1LfltJflnli1 t"wrnu"!lflllfffilfl~" "1 ltl1tlff-'WlL "1~L'lm1L7u"\11n .. • J

" ~ .... ffCl1l.J"""tl11'.J)

D . ... .... ..1 .... " .. -ff1L "1fl::Ll.Jl'.J\4l.J1"flll'l1tl"nffnli1 l.Jtl1 LLL'l::ll11tl1

D WlL "1U~11tl1::\i1t111.h::"D'1"11U ~1!) umiJ111"lfmni El-'Ufl1ll11fl1 Yii'tlllL'111'.JltDWfl.J1tl.JWlL U1

D " .. .... .... tl.. .. ..... ... - • .. ... \Jfl~ll11'.J1l.J1tl-'\11fi!l1\1111'.J 3 QlJlJ (\11fiEl1\1111'.Jfl 1fiWl El1\11'll'.J~1~U1111fl1"D'1 ~1[) El1\111mJff!lU)

ltJ1tl Li'LLl.Jl.J~!lf llfl1llLL \4U

0 Ltlnff11i'm!l..i11uli,, !l.Jfl'WUfli'11 L~uLii !lu,,a..i~tlnm!l.J lflu 1iuflflL'lil-'~tl ltlii'Lilu~fu1v..i .. . .. iJ111"lfm1Vi\!n..,1ufiiff1~n\J1~tiM'4-1ioi'u1e"11ll l~;,1nMlli1ll-'1" 1flui'1~\l'1~1.41u"1"Lilu~i'mD..i . .. 11uli Vi\!n..,1u L'lni1-'L!ln"l1Wui,;flli1.J1i1" 1~tiM'4-1io i'u1on1lll~;,1nMlli"lll-'1" 1flmi1,,a..i .. fi\J n11~~a~ifl n1Til.J1£l.J11 uli £l1~Vi 5w1:: 1 ~ti'M"-1 ftDflJ10'111 ll l~Gl1llU '4UM-i'Dlltl1JtJGt1i111!Sfl11 .. t ..... n .... ... .... ..rvitJ .... fll'.Jfl tl.Jll~ ~ tUl.J1U, 11111"lfn111::flU 5 ,,UL L'l.JU1ll1l.J1!l.J

.. w .

D ~ 1!..i RDi'u1D..i uwfl..i m1u aiii'rn~ Du 1,, uL'l::ii vu..ifi'u'I flu~ a m1fi1 a Liiinu t utl1::L flfll flu •

i1ViLi1"lJE1i'u1E1..i11"liofl11iimilnft11i.i1,f-,~i.iflddh~m1ii\11..iuL'l::nntio..iRiiu7mflmh::m1 ~1n"li1vtLi1 .. .. . liiflllL'lflLil\4L,;";) '!i1YiLi1-v::~lltlHfli .. Lun1Til.JflU~am1ti1E1L1Jinu'I .. . I hereby certify that the above statements are true and correct to the best of my knowledge.

I understand that any falsified information will r8$ult in the disqualification of my scholarship

application.

~~~~~ffi ~ ... ... ., ., ..I

&'l..:J'lilMfflJfl1/ .. . . .. . . .. .•.... ... .. ... . . . .. . . .. . .... .. .. .. .... ... .. .... ... ..... . .. ... 1UYI ... . .... .. .! . .... .... .. ./ ............ . . . .. ( .......................................................................... )

91 Pag c

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AMCHAM THAIL t\!\10

THE AMERICAN CHAMBER OF COMMERCE IN THAILAND

MDn11A10LaJ7n"1"1.h:LY1Altu.1

7th floor, GPF Witthayu Tower A, 93/1 Wireless Road, Lumplni, Pathumwan, Bangkok 10330

Tel: 0-2254-1041 Ext. 224 Fax: 0 -2251-1605. Email:[email protected]

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