ࡱ>     Y R bjbj[[W9 \9 \EC8F F @<@!l"""",,,v;x;x;x;x;x;x;$_>A@;,m,@,,,;"" q<_8_8_8,J8""v;_8,v;_8_8B::"gK.Z:b;<0<b:,UA5UA:UA:,,_8,,,,,;;_8,,,<,,,,UA,,,,,,,,,F , r: NUS (Suzhou) Research Institute NUSRI-affiliated Ph D programme and full scholarship Admission Application Form  If you intend to apply to more than one department, please submit a separate application form, together with another set of supporting documents. To be completed by Applicant [ 1 ] APPLICATION DETAILS Applying to program by : Research Department Applying To : Faculty of Science  FORMCHECKBOX  Biological Sciences  FORMCHECKBOX  Chemistry  FORMCHECKBOX  Mathematics  FORMCHECKBOX  Pharmacy  FORMCHECKBOX  Physics  FORMCHECKBOX  Food Science Technology  FORMCHECKBOX  Statistics & Applied Probability Faculty of Engineering  FORMCHECKBOX  Biomedical Engineering  FORMCHECKBOX  Civil & Environmental Engineering  FORMCHECKBOX  Chemical & Biomolecular Engineering  FORMCHECKBOX  Electrical & Computer Engineering  FORMCHECKBOX  Engineering & Technology Management  FORMCHECKBOX  Engineering Science  FORMCHECKBOX  Industrial & Systems Engineering  FORMCHECKBOX  Materials Science and Engineering  FORMCHECKBOX  Mechanical Engineering School of Computing  FORMCHECKBOX  Computer Science  FORMCHECKBOX  Information Systems [ 2 ] PERSONAL PARTICULARS Name of applicant : Title (Mr / Ms / Mdm) : (As it appears in NRIC/Passport and underline Surname/Family name) Gender :  FORMCHECKBOX  Female  FORMCHECKBOX  Male Marital Status : Date of Birth : Citizenship : Religion : Tel No (Home) : Place of Birth : Country of Residence : Race : Tel No (Mobile) : Email Address (Personal) : Type of ID : Alternate Email: ID Number : Date of Issue : Place of Issue : Date of Expiry: Home Address : Post Code : Mailing Address : (If different from above) Post Code : [ 3 ] PARTICULARS OF NEXT-OF-KIN Name : Relationship : Email Address : Tel No (Home) : Country : Title (Mr / Ms / Mdm) : Occupation : Alternate Email: Tel No (Mobile) : Skype ID : Home Address : Post Code : Mailing Address : (If different from above) Post Code : [ 4 ] LANGUSGESSpokenWrittenLanguagesFairGoodExcellentFairGoodExcellent [ 5 ] ACADEMIC QUALIFICATIONS (Please attach certified true copies of certificates, degrees, and transcripts. Graduates of foreign universities, please use the attached transcript request form for official transcripts to be sent direct from your universities.) Academic History 1 Category : Qualification Type : Qualification : Qualification (others) : Area of Specialisation : If other Specialisation, please specify. Name of Institute : Location of Institute : CGPA/CAP/Average Mark : Name of Institute (Others) : Course Type : Best/Maximum Possible Score : From Date : Completed Degree/Programme : To Date : Expected Completion : Is this course subsidized by Singapore Government or sponsored by any Singapore Government Agency? % No % Yes If yes, please give details below: a. Specify the Government Agency that provided the Sponsorship / Subsidy. b. How many months is the course being subsidized/sponsored? c. Certificate Received Date : e. Academic Rank/Position : d. Expected Complete Date : f. Programme Level : g. Duration of Programme (in months) : Academic History 2 Category : Qualification Type : Qualification : Qualification (others) : Area of Specialisation : If other Specialisation, please specify. Name of Institute : Location of Institute : CGPA/CAP/Average Mark : Name of Institute (Others) : Course Type : Best/Maximum Possible Score : From Date : Completed Degree/Programme : To Date : Expected Completion : Is this course subsidized by Singapore Government or sponsored by any Singapore Government Agency? % No % Yes If yes, please give details below: a. Specify the Government Agency that provided the Sponsorship / Subsidy. b. How many months is the course being subsidized/sponsored? c. Certificate Received Date : e. Academic Rank/Position : d. Expected Complete Date : f. Programme Level : g. Duration of Programme (in months) : [ 6 ] EMPLOYMENT HISTORY Employment History 1 Designation : Name of Company : Date Employed (From) : Nature of Organisation : Type of Employment : Annual Salary (Currency) : Job Responsibilities : Occupation : Industry Sector : Date Employed (To) : Country of Employment : No. of people reporting to you : Annual Salary (Amount) : Employment History 2 Designation : Name of Company : Date Employed (From) : Nature of Organisation : Type of Employment : Annual Salary (Currency) : Job Responsibilities : Occupation : Industry Sector : Date Employed (To) : Country of Employment : No. of people reporting to you : Annual Salary (Amount) : [ 7 ] OTHER ACHIEVEMENTS Achievement 1 Award Type : Institute : From Date : Name of Awarding : Details : To Date : Achievement2 Award Type : Institute : From Date : Name of Awarding : Details : To Date : [ 8 ] TEST DETAILS TestScoreTest DateTOEFLIELTSGATE GREScoreTest DateVerbalQuantitativeAnalyticalTotal [ 9 ] CONFERENCE AND JOURNAL PUBLICATIONS Number of Papers : % International Journals % Books % Local Journals % Proceedings (List Details Below and please attached top page of the publication to this application form.) Please list the details by using the following format:- 1) for Journal Publications: Authors, Title of the paper, Journal name, Volume, Page number (Year) 2) for Conferences: Authors, Title of the paper, Name of the Conference, Place (Date of the conference) [ 10 ] PROPOSED RESEARCHProposed Research Area and Details:  [ 11 ] QUESTIONNAIRE (Please tick " in the relevant box) (a) Are you applying for any other graduate programme in NUS or any other Universities? % No % Yes ( Please give details below) Programme(s) applying for : University : Outcome of application : Successful / Rejected (please delete accordingly) (b) Have you previously applied for admission or been admitted to any postgraduate programme(s) in NUS? % No % Yes ( Please give details below) Programme(s) applied for : Year of application : Outcome of application : Successful / Rejected (please delete accordingly) (c) If you have applied to another department in the Faculty of Science, please state the second department which you have applied to: _____________ ______________________________________ _ (d) Applicants applying to department ofChemistry, please select one research interest from the following: % a. Analytical Chemistry % b. Physical Chemistry % c. Organic / Medicinal Chemistry % d. Inorganic Chemistry [ 12 ] OTHER INFORMATIONDisabilities & Special Needs1) Have you had or do you have any communicable disease, mental illness, colour blindness, and/or disability (including but not limited to chronic illness, visual or other physical constraints or limitations), which may or may not cause you to require special assistance or facilities while studying at the University?2) If 'YES', please provide all relevant information below. This information will allow the University to develop a complete profile of an applicant and to determine whether he/she might need additional resources in his/her studies. The University, however, does not guarantee the provision of special aid (financial or otherwise) to any students. 3) Any Other Information?  [ 13 ] REFEREES Referees1: Name : Occupation : Telephone : Title : Organisation : Email Address : Address : Referees2: Name : Occupation : Telephone : Title : Organisation : Email Address : Address : [ 14] DECLARATION  a. Have you ever been convicted of any offence by a court of law in any country or are there any court proceedings pending against you anywhere in respect of any offence? % Yes % No b. Are you currently, or have you ever been, charged with or subject to disciplinary action for any type of misconduct, scholastic or otherwise, at any educational institution? % Yes % No c. Are you currently, or have you ever been, under investigation or subject to enquiry in respect of any misconduct, scholastic or otherwise, at any educational institution? % Yes % No If your answer to any or all of the above questions is yes, please provide a full statement of relevant information on a separate sheet of paper (and attach the relevant documents). I declare that the information provided by me in connection with this application is true and complete. I understand that any inaccurate, incomplete or false information given or omission of material information required shall render this application invalid and NUS may at its discretion withdraw any offer of admission made to me on the basis of such information or, if already admitted, I may be liable to disciplinary action, which may result in my expulsion from NUS. I understand that the provision of any inaccurate or false information may render me liable to prosecution in a court of law in Singapore. I understand that if I have been convicted of a criminal offence by a court of law of any country, I must submit all relevant information together with this application. I hereby authorized NUS to obtain and verify any part of the information given by me from or with any source, as it deems appropriate. [ 15 ] Personal Data Notice & Consent (i) The National University of Singapore (NUS) manages and administers undergraduate and graduate courses in NUS, including processing applications for the admission of candidates to NUS (Admission). To manage and administer the undergraduate and graduate courses in NUS, including the applications for Admission, NUS will necessarily need to collect, use, disclose and/or process certain personal data or personal information about the individual that has submitted an application for Admission (the Applicant). (ii) Such personal data will be collected, used, disclosed and/or processed by NUS for the purpose(s) of: (a) Processing the Applicants interest in and application(s) for Admission; (b) Administering and/or managing the Applicants application(s) for Admission and Enrolment; (c) Making of any offer(s) of acceptance to courses in NUS; (d) Administering and/or managing the Applicants relationship with NUS (including the mailing of correspondence, statements or notices to the Applicant, which could involve the disclosure of certain personal data about the Applicant to bring about delivery of the same, as well as on the external cover of envelopes / mail packages); (e) Carrying out due diligence or other screening activities (including background checks) in accordance with legal or regulatory obligations or risk management procedures that may be required by law or that may have been put in place by NUS, including the obtaining of references and/or other information about the Applicant from the Applicants previous education institute(s); (f) Responding to any enquiries by the Applicant; (g) Processing the Applicants application(s) for scholarships and/or financial aid as part of the Admission process, and if successful, administering and/or managing the Applicants scholarship and/or financial aid programmes, which may include use of personal data for direct marketing purposes for development and fund raising activities and disclosure of personal data to donors and/or external organisations for purposes of event invitations, surveys and/or publicity of NUS' financial aid programmes; (h) Investigating fraud, misconduct, any unlawful action or omission relating to the Applicants application for Admission, and whether or not there is any suspicions of the aforementioned; (i) Responding to requests for information from public agencies, ministries, statutory boards or other similar authorities (including but not limited to the Ministry of Defence, Ministry of  !Uqrs   # $ % ' ( @ A B ƻ򨡙vh\N\J>hk(hk(5CJaJhk(h4h25CJaJo(h4hk(5CJaJhk(hk(5>*CJaJhh +5CJaJh>sh +5CJaJh h +CJ aJ h!Fh +5 h!Fh +h5Oh +CJaJh +CJaJh +h +CJaJh +h +5CJ aJ h +5CJ aJ o(hI>h +5CJ aJ h +5CJ aJ jh4UmHnHu!qs  $ % @ $d$G$Ifa$gd4l dYD2gdk( dgd +$a$gd + $dG$a$gd +$a$gd +@ A B f siii__UU dgdm dhgdF dgd + dYD2gdk(kd$$Ifl J!  t 0644 l` ap yt4 B W Z [ ] e εΩtdYIh!Fh +CJOJQJaJo(h!Fh +CJaJjhpzCJOJQJUaJ%jhpzCJOJQJUaJh!Fh +CJOJQJaJ%jh!Fh +CJOJQJUaJhmCJOJQJaJh!Fh +5CJaJo(h!Fh +CJaJh!Fh +5CJaJh%dCJaJo(h%dCJaJh%d5CJaJo(h%d5CJaJ      ( ) 7 8 9 : L M N Z [ \ ] ^ x ɾɯɾɯyɾɯfɾɯSɾ%jhpzCJOJQJUaJ%j{hpzCJOJQJUaJ%jhpzCJOJQJUaJh!Fh +CJOJQJaJo(%jhpzCJOJQJUaJh!Fh +CJOJQJaJh!Fh +CJaJ%jh!Fh +CJOJQJUaJjhpzCJOJQJUaJ%jhpzCJOJQJUaJ ( L x 7 w $ ` dgdFvdWD^v`gdm dgd + dhgdFvdWDYD2^v`gdm\dWD8^`\gdm dgdmx y z  . 7 ݺ쟔}q^쟔K쟔%jKhpzCJOJQJUaJ%jhpzCJOJQJUaJhmCJOJQJaJh!Fh +5CJaJo(hm5CJaJh!FhFCJaJh!Fh +CJaJjhpzCJOJQJUaJ%jchpzCJOJQJUaJh!Fh +CJOJQJaJo(h!Fh +CJOJQJaJ%jh!Fh +CJOJQJUaJ7 8 F G H I K n w x       $ % 3 ʺ쯤ݑ쯤~쯤k쯤%jhpzCJOJQJUaJ%jhpzCJOJQJUaJ%j3hpzCJOJQJUaJh!FhFCJaJh!Fh +CJaJjhpzCJOJQJUaJ%jhpzCJOJQJUaJh!Fh +CJOJQJaJ%jh!Fh +CJOJQJUaJ"3 4 5 6 8 X ` a o p q r ɾ~ܠkܠcXMAhmCJOJQJaJh!FhmCJaJhm5CJaJo(hmCJaJ%jwhpzCJOJQJUaJ%jhpzCJOJQJUaJh!FhFCJOJQJaJ%jh!FhFCJOJQJUaJh!FhFCJaJh!Fh +CJaJ%jh!Fh +CJOJQJUaJjhpzCJOJQJUaJ%jhpzCJOJQJUaJ  A B ^ $d$G$Ifa$gd4l \dWD8YD2^`\gdm\dWD8^`\gdm dgdm dhgdm dYD2gd   ! 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(iv) By completing the online application form and clicking the Submit button, the Applicant : (a) Consents to NUS collecting, using, disclosing and/or processing the Applicant's personal data for the Purposes as described above; and (b) Consents to NUS transferring the Applicants personal data out of Singapore to NUSs third party service providers or agents for the Purposes as described above. (v) If the Applicant has any questions relating to NUSs collection, use and disclosure of the Applicants personal data, the Applicant may contact the Data Protection Officer at dpo@nus.edu.sg or call 6776 2835 or such other person as NUS may designate, from time to time, whether by informing the Applicant through any letter, circular, notice or email. 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