Application Form For 1 Semester - ASEAN - 60

Chulalongkorn University
Application form for

One Semester Scholarship Program
for the students from ASEAN Countries
PERSONAL PROFILE (Information
Attach Photo
Here
must be typed)
Mr./Miss/Mrs./Other _______________________________________________________________________
First Name
Male
Sex
Middle Name
Female
Last Name
Date of Birth _____/________/______

Day
Month
Year
Nationality ______________________________Passport Number______________________________

Current Address _____________________________________________________________________
Street
City
__________________________________________________ Tel: _______________________________

State
Zip Code
Country
Fax: _____________________________ E-Mail: _____________________________________________

Proposed level and field of study at Chulalongkorn University:
Bachelors
Master
Ph.D.
Field of study : __________________________________ Faculty: ____________________________

Details of all programs: http://www.academic.chula.ac.th/search/search.asp
Details of all international programs:
http://www.inter.chula.ac.th/inter/internationalstudents/InterProgramList.html
Semester in which you will enroll. The scholarships that we now offer are only for the semesters shown below.
International System
Second (Jan April 2017)
Academic Year 2016
Two-Semester System
Second (Jan- April 2017)
Academic Year 2016
International System is used for all international Bachelors programs and some international graduate
programs.
Two-Semester System is used for all regular programs taught in Thai and for almost all international
graduate programs.
Proposed Grading System for credit transfer to your university:

Standard grading system with A, B, C, D and F
Grading with S for Satisfactory or U for Unsatisfactory (with examination)
Grading with V for Visitor or W for withdrawn (without examination)
1/6
EDUCATIONAL INFORMATION
Home University _________________________________________ Country ___________________
Currently status : Studying Undergraduate/ Year of study..
ID student .
studying Graduate (Master/Ph.D.) /Year of study.ID student

Educational Background
Institution
Location
Major/Field of study
Period of attendance Degree obtained
______________________ _______________ ____________________ ________________ ____________

______________________ _______________ ____________________ ________________ ____________
______________________ _______________ ____________________ ________________ ____________
______________________ _______________ ____________________ ________________ ____________
English Proficiency: (for non-native speaker)
(a) Have you completed a TOEFL test or equivalent in the last twelve month?
Yes, score:_____________________ No
(b) Do you intend to sit for a TOEFL test or equivalent in the immediate future?
Yes
No
If yes, please provide details of test and date.______________________________________________

(c) Indicate your English proficiency
Excellent
Good
Fair
Poor
Thai Proficiency:
(a) Indicate your Thai proficiency
Excellent
Reading
Writing
Speaking
Listening
Good
Fair
Poor
Reading
Writing
Speaking
Listening
2/6
Study Plan: (Please use a separate sheet if necessary.)

Faculty: __________________________________________________
Major: ___________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I declare that the information given is true and correct to the best of my knowledge and that if
I have been awarded a scholarship, I agree to comply with the rules and regulations of Chulalongkorn
University.
Signature of Applicant
Date
3/6
HOME UNIVERSITY APPROVAL : To be signed by Dean of Faculty/Head of Department or Director

of administrative office
We certify that
Mr./Ms.
is our currently
studying an undergraduate student:
Year of study
studying graduate student (Master/Ph.D.)
Year of study
has been approved for participation in the scholarship program for one semester but not more than
4 months for the following periods:
From (Month, year) ________________________
To ________________________
Signed ________________________________________________
(_______________________________________________)
Title_____________________________________________
Date ____________________________________________
4/6
Appendix
Conditions of Scholarships
1. The scholarship period cannot be extended.
2. The recipients are not permitted to accept any employment in Thailand during the term of their
scholarships.
3. The recipients are not permitted to bring any of their family members with them.
4. The recipients are not permitted to postpone a period of the scholarship acceptance as proposed
by Chulalongkorn University.
5. The recipients must residence in Thailand during the scholarship period
In case of the scholarship recipient whishes to leave Thailand during the semester, he/she
has to inform the University of his/her departure through the Advisor where he/she is studying and
the advisor must give assurance that his/her absence will not interrupt his/her studies. Once the
request is approved by the University, the scholarship recipient will be able to depart. In this regard,
the University will not be responsible for the airfare. If his/her absence is more than 10 days,
he/she will not be entitled to the living allowance for the month (s) of his/her absence.
Term of Scholarships :
1 Semester (4 months)
Provisions of the Scholarships :
The scholarships will cover the following :
1. An economy class round-trip ticket to and from designated capital cities or principal cities
2. Tuition and Fees
3. Stipend and accommodation in the amount of 16,000 baht/month.
Health insurance :
Chulalongkorn University has a health service center facility. However, foreign students must have
comprehensive health insurance policy to cover medical services in case of serious illness requiring
hospitalization. If not, all medical expenses incurred will be borne by recipients.
Suspension and termination of scholarships :
These scholarships will be suspended or terminated for the following reasons :
1. Serious illness of recipients.
The recipient is deemed to be seriously ill and not physically fit to carry on with his/her studies.
2. Absence of recipients
Student departs Thailand for over 10 days without the consent of his/her academic Advisor and
approved by the University

I accepted the information provided above is the best of my knowledge. If I have been awarded
a scholarship, I agree to comply with the rules and regulations of Chulalongkorn University.
Signature of Applicant _____________________________ Date ______________
5/6
Please check that you have enclosed all the relevant documents with your application:
A completed application form. [application form for 1 Semester scholarship program for ASENN
Countries]
A nomination letter from home institution/university.
An official transcript of academic records (to be issued by the institute presently being attended)
An English proficiency score record (for non-native speaker of English)*
A copy of passport
A copy of student Card
Study plan / description of academic interests (on a separate sheet of A4-sized paper)
Two 1-inch-colored photos (with blue background) taken no more than six months in polite attire or
the uniform, signed on the reverse side, one of which should be attached to the application form
An appendix.
* International Programs may have an additional required.
Send all application documents directly to the faculty/program of their choice. Please note that the
application date and selection schedule of the applicants has set by each of the faculty/program.
Signature _________________________________________________ Date ___________________________
6/6

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Chulalongkorn University

Application form for

PERSONAL PROFILE (Information

Date of Birth _____/________/______

Nationality ______________________________Passport Number______________________________

__________________________________________________ Tel: _______________________________

Fax: _____________________________ E-Mail: _____________________________________________

Field of study : __________________________________ Faculty: ____________________________

Proposed Grading System for credit transfer to your university:

studying Graduate (Master/Ph.D.) /Year of study.ID student

Period of attendance Degree obtained

______________________ _______________ ____________________ ________________ ____________

If yes, please provide details of test and date.______________________________________________

Study Plan: (Please use a separate sheet if necessary.)

HOME UNIVERSITY APPROVAL : To be signed by Dean of Faculty/Head of Department or Director

studying an undergraduate student:

studying graduate student (Master/Ph.D.)

approved by the University

Signature of Applicant _____________________________ Date ______________

Signature _________________________________________________ Date ___________________________

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Date of Birth _//__

Nationality Passport Number

____________________ Tel: _

Fax: _ E-Mail: _________________

Field of study : ______ Faculty:

______________ _ __

Signature of Applicant _______________ Date

Signature _______________________ Date _