亞洲第一所美國認證大學 The First U.S.-Accredited University in Asia 2015 Summer Program Application Form Personal Information Student English Name Student Chinese Name Last name First name Passport Number Gender University Name Student ID Number at the university Male Female Graduation Year Home Address Student Email Address Telephone Number Cell Phone Number Course Information Choices Course Name Offer Period Total Hours 5454555555 3 Instructor 1 TOEFL Preparation 7/6-8/14 Mr. Toshiyuki Hasumi 2 English Reading & Composition 7/6-8/14 Mr. Toshiyuki Hasumi 3 Cross-Cultural Communication 7/6-8/14 54 54 54 Dr. Adrian Huang Payment Information: You may submit the payment by cash or wire transfer. Course Fee: US$ 1,800 dollars Dormitory Fee: US$ 700 dollars Total Amount Due: Original Price: (Three courses) NT54, 000 MCU Students & Alumni Special Deal: Three Courses: NT45, 000 Single Selection: TOEFL Courses: NT30, 000 (Two Courses) Culture Course: NT15, 000 ATM Transfer Applicant Signature I certify that all of the answers I have given on this application along with the accompanying documents are complete and accurate to the best of my knowledge. I understand that withholding requested information may make me ineligible for admission or may result in dismissal from the academic study camp. Student Signature: Date: Parent/Guardian Signature I have examined the application form prepared by my son/daughter. The application has been made with my full knowledge and support. Parent/Guardian Signature: Date: Parent/Guardian Name (Please Print): Date: