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1. Personal Background 個人資料
Chinese (If Applicable)中文 English*英文
施圣玥
Vernanda Benecia
Applicant’
s Name*
 Please fill in Chinese name if you have one  Please fill in English name as appeared
in the passport
Passport Gender  Male
X1158098
Number* *  Female
Date of
Birth* Place of
2005/May/06 Pekanbaru,Indonesia
(yyyy/mm/dd Birth*
)
Nationalit
Nationality
Indonesia y (2) (if
(1)*
any)
Vernanda.benecia2005@gmail.co Marital  Single
E-mail* m  Married
(Please fill in your current email address)
Status*
Permanent Jln pemuda, komplek sari residence, blok B1/24,PAYUNG SEKAKI, KOTA
Address* PEKANBARU,RIAU
Telephone +62-823-85206542 Cell +62-82385206542
* (+Country code – Area code – Number) Phone* (+Country code – Number)

Father have Taiwanese citizenship  Yes  No

Name in Name
Chinese in Djono
Englis (Please fill in English name as appeared in the passport)
h*
Applicant’s E-mail Passpo
Father* Phone
Addres Djono.sie21@gmail.co rt
Number 0812 68226808 m
X1158097
s* Numbe
*
r*
Place 1971/January/
Occupati National Indonesi TB Date of
a
of 30
on ity* ASAHAN Birth*
Birth* (yyyy/mm/dd)
Mother have Taiwanese citizenship  Yes  No
Name in Name
Chinese in Evi
Englis (Please fill in English name as appeared in the passport)
h*
Applicant’s Passpo
Mother* Phone E-mail
Ngevi888@gmail.co rt
Number 081247968878 Addres X1158086
m Numbe
* s*
r*
Place AEK
Occupati National Indonesi Date of 1972/January/21
a
of KANOPA (yyyy/mm/dd)
on ity* Birth*
Birth* N
Contact Name in Name
Person in Chinese in
Taiwan Englis (Please fill in English name as appeared in the passport)
(if have) h

Komplek Puri Deltamas Blok D No.27

Jl. Bandengan Selatan No.43, Penjaringan, Jakarta Utara 14450
Ph. +62 21-2266-4543 / +62 21-2266-8609
 E-mail
Phone Relationsh
+886- Addres
Number ip
s
Address
in Zip Code
Taiwan
 Same as above Father  Same as above Mother
Name in Name
Chinese in
Englis (Please fill in English name as appeared in the passport)

Emergency h*
Contact* Phone E-mail
Relationsh
Number + Addres
ip*
* s*
Address
in Zip Code
Taiwan

Komplek Puri Deltamas Blok D No.27

Jl. Bandengan Selatan No.43, Penjaringan, Jakarta Utara 14450
Ph. +62 21-2266-4543 / +62 21-2266-8609
2. Educational Background 教育背景
Entry
Degree/Dipl Date
Full Name of City and Date*
Major* oma/Certific Degree
School* Country* (mm/yyy
ate* Granted*
y)
High Darma Yudha Riau,Pekanb High School
science 7/2021 4/2023
School Senior High School aru Degree
University
/ College

Extra- Curricular Activities Basketball

Previous Employment

3. Chinese Proficiency 中文語言能力

If yes, how many years have you
5-6 years
formally studied Chinese ?
Have you ever  Yes
If yes, where did you study
learned Chinese ?*  No
Chinese ? (high school, college, High school
language institute) ?
Have you ever taken If yes, what is the name of the
 Yes Hsk 3
any proficiency test test ?
 No
in Chinese ? Score 258
Listening  Excellent  Good  Average  Poor
Self- evaluation of Speaking  Excellent  Good  Average  Poor
Chinese Proficiency Reading  Excellent  Good  Average  Poor
Writing  Excellent  Good  Average  Poor

4. English Proficiency 英文語言能力

If yes, how many years have you
9-10 years
formally studied English ?
Have you ever  Yes
If yes, where did you study
learned English ?*  No
English ? (high school, college, High school
language institute) ?
Have you ever taken If yes, what is the name of the
 Yes
any proficiency test test ?
 No
in English ? Score
Listening  Excellent  Good  Average  Poor
Self- evaluation of Speaking  Excellent  Good  Average  Poor
English Proficiency Reading  Excellent  Good  Average  Poor
Writing  Excellent  Good  Average  Poor

Komplek Puri Deltamas Blok D No.27

Jl. Bandengan Selatan No.43, Penjaringan, Jakarta Utara 14450
Ph. +62 21-2266-4543 / +62 21-2266-8609