1 序号 文件项目 核对 ( 3 ) 备注

A 部份

1 PASSPORT SIZE 照片共 5 张 (贴在表格上 3 张，另外寄 2 张到本会)

2 团费 RM2,898.00 支票 / 银行汇票 (写申请日期当天，抬头誌明

GMT AGENCY SDN BHD) 背面写上中英名字

3 2019马来西亚华裔青年台湾观摩团团员资料表一份 (编号 : 2)

4 身份证影印本一份

5 家长 / 团员切结书一份 (编号 : 3)

B 部份

6 侨务委员会 2019年海外华裔青年台湾观摩团报名表 (共 4 页)

贴上 1 张照片 家长及申请人必须在最后一张签名 (编号 : 4-7)

7 侨务委员会海外华裔青年台湾观摩团个人资料蒐集、处理及利用

告知事项 (共 2 页) (编号 : 8-9)

8 侨务委员会海外华裔青年台湾观摩团健康证明检查项目表

贴上 1 张照片 (编号 : 10)

9 X - 光检查书面报告 (正本)

10 验血 (B 型肝炎) 书面报告 (正本)

11 护照 (有效日期必须在 2020 年 7 月 1 日以后) 影印本 2 份

C 部份 12 投保申请书

仅填写团员及受益人名字及身分证号码

D 部份

13 2 个 A4 信封 ，每个贴 RM2.00 邮票，並清楚写上自己姓名、地址，

以免延误寄发通知信

2019 年马来西亚华裔青年台湾观摩团申请资料检查表

姓名：(中) ______________________ ( 英) _______________________________________

性别：_______ 年龄: _______ 申请人电话：_________________ 州属: _________________(本会发出讯息以此号码为准)

按照此表顺序一併呈上申請 放在第一張

1A1. 活动名称：2019年马来西亚华裔青年台湾观摩团 1.1. 活动目的：侨务委员会以「认识中华民国台湾」为主轴，以「行动式生活教学」之方式，让马来西亚青年透过 动态与静态的参访与学习，亲身体验中华传统文化之精髓与传承、台湾多元文化之融合力与创造力，並对台湾 各地人、事、物、景及各项政经社教发展现况有深刻的瞭解、体验与认同，达到传扬台湾多元文化、扩增青年 国际交流及搭建两国青年友谊橋樑 1.2. 活动内容：以认识中华民国台湾，增进国内外青年交流为主题之参访观摩活动，为期 3週。

2. 主办单位：中华民国侨务委员会

3. 承办单位：国立台中科技大学

4. 指导单位：驻马来西亚台北经济文化办事处

5. 筹组单位：马来西亚华裔青年台湾观摩团辅导委员会

6. 行程日期：2019 年 12 月 11 - 31日 (共 21 天)

7. 行前说明：2019 年 12 月 10 日 (所有团员必须参加)

8. 团费：RM2,898.00 (含吉隆坡 / 台北往返机票，旅游保险、行前说明会膳宿、送往机场交通、服装、感言特辑、在台 团员健康保健、行程由侨务委员会支应新台币贰万元)

9. 注册费：每人新台币 12,000元整 (团员自行带去台湾缴交予承办单位)

10. 申请说明: 10.1. 凡居住在马来西亚，身心健康、学行良好，能适应团队生活之华裔青年男女年龄 15-25 岁 (1994至 2004出生 者) 皆可申请 10.2. 为使参加机会均等普及，以未曾参加者优先录取，同一家庭不限申请人数 10.3. 团员必须全程参与，所有团员必须随团赴台湾及返回马来西亚，不得在台湾延期居留 10.4. 患有精神心理疾病、严重痼疾、癫痫症、传染病或其他随时可能发生身体重大症状者，不得报名 10.5. 活动期间若宿疾复发或突发病症，送医所需医疗等费用，团员及其家长应自行负担，与主 / 承办 / 筹组单位无涉 10.6. 为安全考量，若团员在行前说明会报到时，发现疾病缠身或已有身孕者，将不予放行随团参加，团员必须立即 返家 10.7. 支票一旦过帐，视同录取，获录取者不可因故申请退团，缺额由本会遴选填补，不得自行递补，所缴费用恕不 退还，或视情况扣除行政费用

11. 必备文件: 11.1. 本会印制团员资料表一份， 並贴上一张照 11.1.1. 资料表内推荐单位可请人民代议士、校长、社团领袖或观摩团历届团长或干部签名推荐 11.2. 侨务委员会 2019 年海外华裔青年台湾观摩团报名表 (共 4 页) 並贴上一张照片 11.3. 侨务委员会海外华裔青年台湾观摩团个人资料蒐集、处理及利用告知事项 (共 2 页) 11.4. PASSPORT SIZE 近期照片 5 张 (3 张贴在表格上，另外附上 2 张寄到本会) 11.5. 家长 / 团员切结书一份 11.5.1. 2 个 A4 信封贴上 RM2.00 邮票， 並清楚写上自己姓名、地址 11.6. A. 身份证影印本 1 份 B. 护照影印本 2 份 (有效日期必须在2020年 7 月 1 日以后) 11.7. 团费 RM2,898.00 支票或银行汇票 (写申请日期当天支票，抬头誌明 GMT AGENCY SDN BHD，未被录取者， 原票退还) 11.8. 投保申请书 (仅填写自己所知道的部份即可) 11.9. 侨务委员会海外华裔青年台湾观摩团健康证明检查项目表含 X 光暨 B 型肝炎检验书面报告並贴上一张照片 11.10. 资料填妥、文件准备好后请径寄: 马来西亚华裔青年台湾观摩团辅导委员会 GMT AGENCY SDN BHD 8A, JALAN CUNGAH, 42000 PORT KLANG, SELANGOR, MALAYSIA. TEL：016 - 332 3158 E-mail：guanmotuan16@gmail.com

12. 报名截止日期：2019 年 5 月 31 日 (以邮戳为凭，逾期不受理)

13. 正式名单预计於 8 月下旬发佈，被录取者将接获本会发出电话简讯及正式信函通知

14. 本会採全国十四州属机会均等原则，申请者务必妥善准备所须文件，缺一不可，敬请留意

15. 本会依据侨务委员会 2019 年海外华裔青年台湾观摩团筹组须知办理

2019 年马来西亚华裔青年台湾观摩团申请须知

21. 姓名: (中) ________________________ (英) __________________________________ 性别: 男 □ 女 □

2. 出生日期: _____________ 身份证号码: ___________________ 报生纸号码: ___________ 年龄: ________

3. 护照号码: ______________ 有效日期: __________________ 婚 / 已婚 (配偶姓名) ___________________

4. 电话: 家 _________________ 手提: _______________________ 电邮: ____________________________

传真: ___________________ 紧急联络电话: _____________________

5. 身高: _______ cm 血型: _______ 体重: ________ kg 衣服尺码: S / M / L / XL / XXL 餐别: 一般 □ 素食 □

6. 学历: ______________ 职业: __________________ 公司 / 学校: _________________________________

就读年级 / 班别: ____________________________ 宗教: ___________

7. 永久地址: _____________________________________________________________________________

_____________________________________________________________ 邮编: __________________

8. 父亲姓名: (中) ___________________ (英) __________________________________________________

9. 母亲姓名: (中) ___________________ (英) __________________________________________________

10. 曾否参加观摩团 / 客家营? __________ 年 曾经报名未被录取: ______________ 年

家中有成员曾经参加观摩团 / 客家营? 姓名: ___________________ 年度: __________ 关係: __________

11. 参加活动 / 团体经验: (请填写三项最具代表性之记录)

活动 / 团体名称 参加年度 担任职务 地点 备注

12. 专长: 1. __________________________ 2. __________________________ 3. _________________________

13. 参加观摩团的期待 / 原因是 _______________________________________________________________________

_____________________________________________________________________________________________

14. 是否愿意为观摩团服务? 愿意 □ 不愿意 □

15. 今年是否参与 STPM / SPM 考试？有 □ 没有 □

我确认以上所填属实，且誓言遵守规章，遇有不实，自愿棄权；並同意支票过帐后视同录取, 将不申请退团退费。

支票 / 汇票号码: ________________________ 报名截止日期: 31.05.2019

银行名称: ___________________________________________ 分行 ______________________

申请人签名: _____________________________ 家长签名: ________________________________ (所有申请人均必须具家长签名，否则不予受理)

推荐人/单位:_______________________________ 日期: ______________________________________

2019年马来西亚华裔青年台湾观摩团团员资料表

编号:

贴照片一张

32019 年马来西亚华裔青年台湾观摩团

家长 / 团员切结书

本人 (家长姓名) ___________________ (英) ___________________________________

身份证号码: _____________________________ 同意吾儿 / 吾女

团员姓名: ____________________ (英) _______________________________________

身份证号码: ______________________ 护照号码: _______________________________

1. 参加本年台湾观摩团，並将督促遵守所定规章；

2. 本人同意吾儿 / 吾女於自由活动日与亲戚朋友外出，唯必遵守相关规定

3. * 吾儿 / 吾女确曾患 __________________ 病历，如今已无大碍

若於活动期间遇有状况，概由本人承担责任归属，与主办、承办及筹组单位无关。

特具此书。

紧急联络人: ______________________________________________________

联络电话 : ______________________ (手提) : __________________________

家长签名 : ______________________ 团员签名 : _______________________

日 期: ___________________

* 遇有相关情事者请填写

敬致:

4侨 务 委 员 会 OCAC, Republic of China (Taiwan)2019年侨务委员会海外华裔青年台湾观摩团报名表Application Form for 2019 Compatriot Youth Taiwan Study Tour

中文姓 NAME IN CHINESE

名 英 文 NAME IN ENGLISH First Name (Capital Letters) Last Name

出生地 出生日期 性别 □ 男 □ 女PLACE OF BIRTH DATE OF BIRTH Month day year SEX Male Female

国籍 住址 (Capital Letters)

NATIONALITY HOME ADDRESS

电话 TEL 传真 FAX 电邮 E-mail

饮食习惯 □ 荤食 □ 素食 □ 其他

是否曾学习华语 □ 是 年 □ 否 华语程度 □ 零程度 □ 初级 □ 中级 □ 高级

护照 发照地点 号码 失效日期PASSPORT PLACE OF ISSUE NUMBER DATE OF EXPIRY

父母资料 PARENTS (Give complete addresses only if different from home address above)

父亲 FATHER (In Chinese) 母亲 MOTHER (In Chinese)

姓名 NAME

服务机构 OFFICE OR COMPANY

参加侨团或侨社 O. C. SOCIETY

在台亲友紧急联络人 (20 岁以上) RELATIVE OR FRIEND FOR EMERGENCY CONTACT IN TAIWAN (Above age 20)

姓名 电话 TEL （ ） 与本人关系

NAME IN CHINESE 传真 FAX （ ） RELATION

服务机构 OFFICE OR COMPANY 职称 POSITION

观摩研习梯次 WHICH TERM ARE YOU APPLYING FOR？

□ 第 8 梯次 8th Term (Malaysia) (2019年12月11日至31日)

® 是否患有下列疾病？ Do you have any of these diseases？ □ 否 NO

□ 痼疾 CHRONIC DISEASE, ex： □ 精神心理疾病 PSYCHOGENIC ILLNESS

□ 癫痫 EPILEPSY □ 心脏脑血管病变 CARDIO-VASCULAR DISEASE

如患有上列疾病或其他重大身体不适症状（如糖尿病、传染病或怀孕等）足以影响活动之进行，请勿报名参加，抵台后如经发现患有

以上病症致发生事故者，应自行负责，並负担医疗及返回侨居地等相关费用。Please do not apply for admission, if you have any of the above mentioned diseases or any symptoms such as diabetes, epidemics or pregnancy which may affect the participation of the activity. If any of the above mentioned medical conditions is discovered after arriving in Taiwan, the student must pay his/her own medical and return expenses

请注意本页每栏务必须填写，否则申请表件不予受理。 Please note that all information must be completed; otherwise your application won’t be accepted.

填写报名表前，务请先详阅招生简章各项说明与规定。 (Please read admission guidelines carefully before filling out the application form.)

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5一、活动内容：以认识中华民国台湾，增进国内外青年交流为主题之参访观摩活动，为期 3週。

二、团员於活动前，应先参加行前说明会，以瞭解观摩团之意义及应行注意事项，俾抵台后能适应团体生活，遵守团体纪 律。

三、报名须知：

1. 年满 15 岁足岁至未满 25 岁 (以护照所载年龄为凭)，目前居住於海外，身心健康、学行良好並能适应团队生活之 华裔青年，报名者须具高度学习意愿、且能全程参加活动並愿接受团队管理纪律之自愿者。

2. 费用： （1）观摩团团（职）员应缴交新台币 12,000 元整，於报到时缴交承办单位，中途离团者，不予退费。 （2）观摩团团（职）员来回机票、个人零用金、在侨居地参加保险之保险费、医疗等费用自行负担，其在台湾观 摩 3週之膳、宿、交通等费用均由侨务委员会支付。

3. 申请人必须准备 1吋半身 (2.54cm) 照片 5 张、侨居国护照。

4. 如有疾病或重大身心不适症状 (例如心脏病、脑血管疾病、糖尿病、精神病、癫痫症、传染病、怀孕等) 可能影响 活动之正常参加者，请勿报名，否则如因此发生事故，应自行负责，与主、承办单位无涉。

5. 凡已核准回国升学之侨生，不得报名。报名未经核定者不得随团活动。

6. 曾有吸毒、犯罪前科或其他品行不佳者，不得报名。

7. 观摩团团（职）员应于出发前于当地办妥个人医疗保险，观摩期间如因疾病就医治疗，应自行负担医疗费及返回居 留地费用，团员及其家长不得向主办单位（侨务委员会）或承办单位提出任何要求。

四、活动应遵守事项：

1. 如观摩团团（职）员於活动期间发生任何意外事故，主办单位及承办单位仅就有故意过失部分负责。

2. 观摩团团（职）员在活动期间不接受辅导或不遵守规定事项，致发生意外事故应自行负责，主、承办单位除有重大 过失外，对该团（职）员不负任何赔偿责任，如有任何争议皆依中华民国法律处理。

3. 团员携带行李应简单轻便，不得携带任何违禁品及保育类动物製品。

4. 请切实遵守中华民国海关规定，办理行李通关手续，並请各筹组单位酌情统一製发大型显明之标帜贴於团员行李 上，以便管理，避免遗失。

5. 请携带轻便夹克（在山区住宿，早晚较凉）及球鞋等，以应各种场合穿著。

6. 请团员依活动规定日期抵台及离台，如因机位等因素必须提早或延后，停留期间一切费用自理。观摩活动行程结束 后，团员应即返回侨居地，不得以任何理由，或以侨生、留学生身分留台升学或居留。

7. 如因团员之违法行为或其它可归责於团员之事由，致遭政府机关羁押或留置时，应由该团员自行负责，与主、承办 单位无涉，並应负责赔偿本观摩团活动主、承办单位因此所受之一切损害。

8. 团员须全程参加活动，不得私自离团，若有特殊情形必须提前离团者，应由家长出具申请书说明原因，由驻外馆处 或华侨文教服务中心转送侨务委员会核准后，通知承办单位依程序办妥离团手续后方可离团。

9. 团员於活动期间不接受辅导或不遵守规定事项，情节重大者，经查证属实，侨务委员会得径予退训处理，团员及 家长不得異议，且未来参与本活动须全额自费，侨务委员会将不予补助。

2019 年海外华裔青年台湾观摩团 活动须知

1. Objective of this Study Tour: To learn about Republic Of China (Taiwan) as well as to promote international youth exchange. This program will take three weeks.

2. Before you attend this Study Tour, you should attend the introductory seminar, so that after you arrive in Taiwan, you will have better understanding of the Study Tour as well as its rules and regulations.

3. Qualifications for Registration: (1) The applicants must be overseas Compatriot youth between the ages of 15 and 25 (a copy of the passport is required) who are in good health and academic standing, currently live overseas, have high learning desire; and are willing to obey group regulations and disciplines as well as willing to take all of the courses. (2) Expenses: a. Registration fee: NT$12,000 is required for each participant. There will be no reimbursement of registration fee if participants leave during the Study Tour. b. Participants are responsible for their own round trip airfares to and from Taipei, medical and travel insurance premiums, and personal expenses. However, the OCAC, Republic of China (Taiwan) will provide accommodations, meals, and transportation within Taiwan.

Admission Guidelines for 2019 Compatriot Youth Taiwan Study Tour

6 (3) The applicants are required to submit 5 original passport-size pictures （1/2”or 2.54cm X 4cm）, a valid passport to Taiwan. (4) Each applicant must be in good health (free of heart problems, cardio-vascular illness, diabetes, mental disorder, epilepsy, infectious disease, pregnancy and others that may cause serious symptoms) in order to participate in the Study Tour. Otherwise, participants are responsible for any accident occurred. (5) Students who already have the approval from the government agency to study in Taiwan will not be allowed to attend this Study Tour. All applicants must receive approval from OCAC, otherwise the applicants will not be accepted to the Study Tour. (6) Applicants who have criminal records or drug abuse problems will not be allowed to attend. (7) Participants should buy medical insurance before leaving for Taiwan. If participants are sick and have to stay in the hospital during the Study Tour, they will have to pay their own medical and return expenses. Requests by parents for medical compensations from the OCAC and undertaking agency will not be accepted.4. Rules and Regulations: (1) Tour sponsors are not responsible for any accidents during the period of tour except for any incident occurring as a result of negligence caused by tour activities. (2) Participants are responsible for any accident caused by not following the advice, rules and regulations. The sponsors will not be held financially liable for any incidents except for the occurrence of significant negligence on the part of the Tour organizers. If any dispute occurs, the laws of Taiwan will prevail. (3) Simple luggage is more appropriate. Contraband articles and endangered species products are prohibited. (4) Follow the rules and regulations of the Customs; the respective committee should make special stickers / signs so that the participants may use them to avoid their luggage being lost. (5) Please bring semi-formal attires with ties, shirts, and slacks for males, skirts and blouses for females, and light jackets for mountain areas, and sneakers for outdoor activities. (6) All the participants must set their arrival and departure dates according to the study tour schedule. No changes will be allowed. For any changes in these schedules, study tour participants are responsible for all additional expenses. After the study tour ends, participants must return to their resident countries within the scheduled visa stay period. (7) Any infractions of Taiwan’s laws or evidence of contribution to such resulting in punitive actions by the R.O.C. government or law enforcement officials towards a tour participant will be left to that individual own responsibility. The tour organizers will not be held responsible for any such actions. Consequently, the tour sponsors may also request compensations for any inconveniences caused by this individual or situation. (8) All participants must attend the whole tour according to the Study Tour schedule. No changes will be allowed. For any changes in the schedule due to certain special situations, participants must have parents’ petition (with the explanation of changes) with the final approval from OCAC in order to leave. (9) All applicants must follow the group regulations and guidance. For serious circumstances, under the true investigation from OCAC, the applicants will be withdrawn from the Study Tour, and the objection from applicants and parents will not be accepted, and applicants must pay all of related fees for joining this program in future.

本人保证以上所填资料均属实且将遵守本活动各项生活辅导规定 (详如以下生活辅导标准表)，若有违反，愿接受处罚，倘如已达到离开本活动之规定，愿自动放棄研习资格，立即离营，並不得要求退还已缴交之活动费用。此致

侨务委员会

As an applicant of the program, I certify that all of the above information provided is true to my knowledge and I am willing to observe and abide by all the regulations of the OCAC Compatriot Youth Taiwan Study Tour. I understand that if I violate these regulations as listed in the following demerit table, I will accept the corresponding demerit. Once I have reached the demerit limits, I will unconditionally forfeit the right to participate in the program and will depart immediately upon the request of OCAC , Republic of China (Taiwan) without requesting the reimbursement of the program fee.

学员签名 家长签名 日期Applicant’s Signature: Parent’s (Guardian’s) Signature: Date: 　　

电话 Phone: 电传 Fax:

住址 Home address:

研习同意书 ENROLLMENT AGREEMENT

7 Behavior 事由 Frequency or Punishment or Time Period Point deduction 次数或时数 处罚或扣分

Theft (You will be reported to the police.) (偷窃物品，移送法办) Sleeping in the room of the opposite sex overnight. (在異性房间过夜) Severe fights will be reported to the police, and the payment for the damages or medical Once Dismiss services must be made. (严重斗殴送警法办外，並须负赔偿责任) 一次 退营 Drug taking will be reported to the police. (吸毒者送警法办)

Being late for bed-check. (晚点名迟到) 0.25

Sick leaves. (病假) One Hour 0.15

Leaving on personal matters. (事假) 一小时 0.25

Unexcused absence from activities. (无故不参加活动) 1

Being late for activities. (参加活动迟到) Leaving activities before dismissal. (参加活动早退) 0.1 Playing with cell phones or iPads during class time. (上课把玩手机或平板电脑)

If you didn’t fill out any permission forms for leaves, it will result in a point deduction. 0.5 (未依规定填写请假单)

Smoking in non-smoking areas. (在非吸烟区内抽烟) Being noisy after bed-check and failing to behave. (深夜吵闹，不听劝阻) Once Leaving the accommodation without permission after bed-check. (晚点名后不假外出) 一次 Putting up people who are not the program participants in your room. (带外人进入住宿房间) 1

Drinking alcohol, gambling, fighting with others during program period. (在研习期间喝酒、赌博和打架) Damaging public properties. (You will have to compensate for the damaged property 2 according to its price.) (破坏公物，另须照价赔偿) Staying in the room of the opposite sex after bed-check. (晚点名后在異性房间逗留)

Staying overnight without filling in the Overnight Absence Form. (不假外宿) 4

Loudly playing music anytime. (音响音量过大) Confiscate the articles until the end of Playing with dangerous articles, i.e. air gun / toy gun / laser pen. the term (没收器材至离营时发还) (使用具危险性器材，如：空气枪 / 玩具枪 / 雷射笔)

1. Each participant starts with 15 discipline points. 每位学员报到时生活辅导总积分为15 分。 2. If you behave well and have no deduction during a whole week, your discipline points will be added 0.5 point. 如整週表现良好且未扣分者，当週生辅成绩加 0.5 分。 3. If you need to ask for a leave, please report to the program staff or counselors in advance. All leave-asking procedures should be submitted in three days including the day you ask for a leave, otherwise you will be considered as having a leave without permission. 如需请假请事先告知各相关人员，所有请假手续须於请假当日起 3 日内办理完成，否则皆以无故不参加活动论。 4. If your discipline points are lower than 7 points, you will be required to leave the program immediately without reimbursement of the program fee. 研习期间生辅成绩未达 7 分者必须离开本营队，所缴交活动费用不予退还。 5. If participants are caught stealing, fighting or gambling, the police may become involved at the discretion of the program organizer. 在营内或营外发生偷窃、打架或赌博等不良行为，将视情况报警处理。

注意事项 Notices：一、研习同意书须有学员及家长之签名始得认可，否则将无法办理报到手续。 Participants without cosigned Enrollment Agreement by the parent will not be allowed to register.

二、兹为提高研习品质及维护学员安全，特订定生活辅导标准表如下，请参加学员确实遵守。 In order to promote program quality and to maintain participants’ safety, the OCAC will administer the following group regulations.

以下请勿填写（审核用）Please do not write below this line（FOR OFFICIAL USE ONLY）

审查单位 初审

(政府驻外馆处或华侨文教服务中心)

审查意见 1. 申请人确实具备华裔身分？ □ 是 □ 否

2. 送审证件及所填资料是否齐全、属实？ □ 是 □ 否

3. 曾否参加本活动？ □ 是 年 月 □ 否

◎ 务请加盖受理单位章戳 或审查人印章

审查日期 年 月 日

印鉴

8一、依据：个人资料保护法 (以下简称「个资法」)第八条规定。1. Pursuant to: Article 8 of the Personal Information Protection Act (hereafter “the Act”).

二、机关名称：侨务委员会（以下简称「本会」) 及受本会委托办理本活动之 单位。2. Agency (name): The Overseas Community Affairs Council (hereafter “OCAC”), and the unit it assigns to carry out this activity.

三、蒐集之目的： 基於办理本会海外华裔青年活动相关之招生、核录、办理保险等相关讯息发送之资 (通) 讯服务、学员联繫、学员资料 与资料库管理、统计研究分析、学术研究及其他完成本会活动营务及侨务必要之工作，或经学员同意之目的。3. Reasons for gathering information: For performing necessary services when holding OCAC Overseas Chinese Youth activities, including enrollments, acceptance letters, insurance, and other matters; tasks involving student contact information and personal database management, statistical analysis, academic research, and other tasks required by the OCAC to run its activity and overseas community affairs; and other uses approved by the applicants.

四、个人资料之类别： （一） 辨识个人者 (C001)：中英文姓名、职称、自传、相片、住址、出生年月日、出生地、居住地区、通讯地址、 电话、行动电话、传真、电子邮件信箱等。 （二） 辨识财务者 (C002)：保险单号码。 （三） 政府资料中之识辨者 (C003)：身分证统一编号、护照号码、保险凭证号码及证照号码等。 （四） 个人描述 (C011)：出生年月、性别、国籍及居住地区等。 （五） 身体描述 (C012)：身高、体重及血型等。 （六） 习惯 (C013)：饮食习惯。 （七） 家庭其他成员之细节 (C023)：家庭其他成员或亲属、父母、同居人及旅居国外及大陆人民亲属等。 （八） 其他社会关係 (C024)：朋友、同事及其他除家庭以外之关係等。 （九） 移民情形 (C033)：护照、工作许可文件、居留证明文件、移民资料、入境之条件及其他相关细节等。 （十） 慈善机构或其他团体之会员资格 (C037)：侨团、侨社、侨商会会员。 （十一） 职业 (C038)：职业、职称。 （十二） 现行之受雇情形 (C061)：雇主、工作描述、产业特性等。 （十三） 健康纪录 (C111)。 （十四） 种族或血统来源 (C0113)。4. Types of information gathered: (1) For identifying the individual (C001): Chinese and English name, job title, autobiography, biography, photograph, date of birth, place of birth, place of residence, address, tel. no., mobile phone no., fax no., email address. (2) For verifying financial information (C002): Insurance policy number. (3) For identification in government documents (C003): ID card no., passport no., insurance certificate no., license no. (4) Personal description (C011): Month and year of birth, sex, nationality and residence. (5) Body description (C012): Height, weight and blood type. (6) Habits (C013): Dietary habits. (7) Information on other family members (C023): Family members, relatives, parents, common-law partners, and relatives living overseas or in Mainland China. (8) Other social relationships (C024): Relationships with friends, colleagues and others outside the family. (9) Immigration situation (C033): Passport, work permit, residence permit, immigration information, entry conditions and other related details. (10) Membership of charity organizations or other groups (C037): Overseas Chinese groups, overseas Chinese chambers of commerce. (11) Occupation (C038): job, position. (12) Current employment situation (C061): employer, work description, characteristics of industry. (13) Health records (C111). (14) Race or ethnicity (C0113).

五、个人资料处理及利用： （一） 个人资料利用之期间： 自报名本会活动起至上开蒐集目的完成所需之期间为利用期间。 （二） 个人资料利用之地区： 台湾地区 (中华民国境内)、当事人居住地或经当事人授权处理、利用之地区。 （三） 个人资料利用之对象： 本会、本会驻外侨务秘书或驻外馆处（协助本会遴荐参加人员及业务联繫之必要情形下，利用本会提 供之当事人个人资料)、本会业务委外之委办厂商（本会活动委外合约业明订委办厂商得利用本会提供之参加人员 个人资料时，应遵守个资法相关规定）及经本会同意得运用之学术研究单位、学者专家等。

侨务委员会海外华裔青年台湾观摩团个人资料蒐集、处理及利用告知事项OCAC disclosure regarding gathering, handling and using personal information of

participants in the Program for Expatriate Youth Taiwan Study Tour

9 （四） 个人资料利用之方式： 执行本会业务，包括本会举办之各项活动如招生、錄取、保险、订房、参访、拜会机关等证明及相关讯息 (寄) 发送通知、当事人之联络、资料统计分析、办理本会业务必要揭露、学术研究及其他等有助上开蒐集目 的之必要方式。5. Handling and use of personal information: (1) Utilizing period: From the time of application to the OCAC activity to the completion of the aforementioned information gathering. (2) The region within which personal information will be used: Taiwan (within the ROC), the place of residence of the party involved, or places where handling and use has been approved by the party involved. (3) Users of personal information: The OCAC, the OCAC’s secretary office or embassy/consulate/representative office (personal information of the person involved can be provided to them by the OCAC when selecting participants or for contact purposes), suppliers contracted by the OCAC (the outsourcing contracts for OCAC activities clearly state that when a supplier needs to use the personal information of participants, the regulations of the Act must be obeyed), and research units and scholars and experts authorized by OCAC. (4) Way of using: Carrying out the OCAC’s operations, such as sending enrollment forms, acceptance letters, insurance matters, room reservations, visiting organizations and other certificates, and sending of related information, contacting the person involved, statistical analysis, necessary disclosure of the OCAC’s operations, academic research and other necessary methods for achieving the aforementioned collection objectives.

六、当事人得依个人资料保护法规定查询或请求阅览；请求製给复製本；请求补充或更正；请求停止蒐集、处理或利 用；请求删除。当事人得以书面与本会联繫，行使上述之权利。6. In accordance with the Act, the person involved can inquire about the information or request to read it; they can ask for copies ,and ask to cease the use and handling, and for deletion. The person involved can exercise the above rights by submitting a hard copy in writing with this request to the OCAC.

七、学员如未提供本会办理活动所需之正确完整个人资料，应註明正当充分之理由，否则将无法进行报名手续並丧失享有 活动后续服务之权益。7. If an applicant does not provide complete and correct information for the OCAC to carry out this activity, he/she should fully state the reason for this. Otherwise, the application cannot be processed, and the applicant will lose the entitlement to subsequent services connected with the activity.

(Adult applicant 成年者) 本人 (Chinese Name) (English Name：)

(Minor applicant 未成年)本人 (Guardian’s Chinese Name) (English Name：) 係

(Chinese Name） (English Name：) 之法定代理人

业已详阅、瞭解且同意所附「海外华裔青年台湾观摩团个人资料蒐集、处理及利用告知事项」。I have carefully read and understood the attached OCAC disclosure regarding the gathering, handling and using of personal information of participants in the Program for Expatriate Youth Taiwan Study Tour, and I hereby agree to it.

此致 To:侨务委员会OCAC

立书人（已成年之报名者或未成年报名者之法定代理人）：Applicant (adult applicant or legal guardian of minor applicant)

（Signature）身分证字号（ID or Passport No.）：

Country：

Address：

Tel：

Date:

10侨 务 委 员 会 编号: OCAC, Republic of China (Taiwan)海外华裔青年台湾观摩团健康证明检查项目表Items Required For Health Certificate

中文姓名：

检查日期 Date of Examination

Name in English:

日(D) 月(M) 年(Y)

性别Sex： □ 男 Male □ 女 Female 护照号码 Passport No：

出生年月日 Date of Birth： / / 国籍 Nationality：

身体检查 PHYSICAL EXAMINATIONA. 身高 Height： 公分 cm

B. 脉搏 Pulse： 次 / 分 time / min

C. 血压 Blood pressure： / 毫米汞柱 mm Hg

D. 心脏 Heart： □ 正常 Normal □ 異常 Abnormal

E. 体肢运动 Locomotors： □ 正常 Normal □ 異常 Abnormal

F. 疝气 Hernia： □ 正常 Normal □ 異常 Abnormal

G. 体重 Weight： 公斤 Kg / Lb

H. 视力 Vision： 右 Right 左 Left

检验室检查 LABORATORY EXAMINATIONS

® 未作本项目检查者，将不予受理。【Application missing this information will not be accepted.】

A. 胸部 Ｘ 光检查肺结核 Chest Ｘ-Ray for Tuberculosis： □ 正常 Normal □ 異常 Abnormal

B.Ｂ 型肝炎表面抗原检查 Hepatitis Ｂ Surface Antigen： □ 阳性 Positive □ 阴性 Negative

病史 MEDICAL HISTORY* 您是否曾经感染下列疾病 Have you ever had the following diseases ？

A. 心脏病 Heart disease： □ Yes □ No

B. 气喘病 Asthma： □ Yes □ No

C. 高血压 Hypertension： □ Yes □ No

D. 糖尿病 Diabetes： □ Yes □ No

E. 癫痫 Epilepsy： □ Yes □ No

F. 肾脏病 Kidney disease： □ Yes □ No

G. 疟疾 Malaria： □ Yes □ No

H. 肝病 Liver Disease： □ Yes □ No

结论：根据以上对 先生 / 小姐之检查结果，他 / 她 □ 是 □ 不是 合格的。

CONCLUSION：Above is the medical report of Mr. / Ms He / She □ Is □ Is not fit。

医院（诊所）名称、地址、电话 负责医师签章

Hospital’s or Clinic’s Name, Address and Telephone Chief Physician： (Name & Signature)

医院负责人签章

Superintendent： 日期 Date：日 (D) 月 (M) 年 (Y) 20 (Name & Signature)

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