Name of applicant:

Departure date you wish:

Attach two photos here

DOB     Month:     Day:    Year:      

MALE        

Birth place:

FEMALE   

List your special talent & sport(s):

Single Room: 

Yes     No 

Name of your roommate

Which language do you speak / know Chinese  English   

 Other  __________________________

Home Address:

Father’s/Guardian’s name:

Occupation:

Mother’s/Guardian’s name:

Occupation:

Tel (Home):

E-mail:

Tel (Work:)

Fax:

Medical Insurance number:

Your doctor’s phone:

Name of relatives in China:

Relation to the applicant:

Address of your relatives & phone number:

Nationality:

Passport number:

Place of issuance:

Expiration date    month:    Day:     year:

1.You do not plan to return with group               

2.You do not wish to engage in group activities 

Date:

Signature of applicant

Date:

Signature of parents or Guardians