PhD Dissertation/Thesis Form

PhD Dissertation/Thesis Form: 002

Republic of the Philippines
Bulacan State University
City of Malolos

菲律賓比立勤國立大學

PhD DISSERTATION SUPERVISOR
REGISTRATION FORM

博士論文導師
註冊表格

申請註冊導師資料 Details of Applicant for Supervisor Registration:

姓名:                                                                                              
Name:  ______________________________       ____________________________________________________
                           (中文 Chinese)                                                   (英文 English)                      

男             女                 婚姻狀況:      已婚                          未婚                      其他            
Male    Female                     Marital Status:     Married (M)               Single (S)              Others (O)

出生日期：               出生地點：                                             (省/市)#p#分頁標題#e#
Date of Birth ： _______ /_______/_______ Place of Birth ：________________/_____________(Province/City)
                           (dd)        (mm)      (yyyy)

身份證／護照編號:              簽發地點：                簽發日期：
Identity Card/ Passport No.: ______________ Place of Issue: ____________ Date of Issue: _______/________/_______

通訊地址：                                                                                                                                              
Correspondence Add.ress:__________________________________________________________________________________________

辦公地址:
Office Address:_____________________________________________________________________________________

住宅電話：                 辦公電話：                                  電郵:
Phone (Home): ___________________(Office): _____________________ Email Add. : __________________________

住宅傳真：                 辦公傳真：                                  手機/傳呼號碼:
Fax (Home): ____________________ (Office): ______________________ Mobile/ Pager No.: ____________________

工作經歷:
Working Experience

公司名稱
Name of Employer 你的職位名稱#p#分頁標題#e#
Your Job Title 工作職權和責任
Duties and Responsibilities 受聘日期
Dates of Employment
 
  從               到
From:         To:

   從               到
From:         To:

 
  從               到
From:         To:

 
  從               到
From:         To:

 
  從               到
From:         To:
 
學術資歷
Academic Qualifications

頒發機構
Awarding Institution 學歷或學位名稱
Title of Qualification 就讀日期
Period of Study 結業日期（年）
Year Completed

專業資歷
Professional Qualifications

頒發機構
Awarding Institution 資格名稱
Title of Qualification 就讀日期
Period of Study 結業日期（年）
Year Completed
   
   
公職服務資歷
Public Service Information

機構
Institution 你的職位名稱
Your Job Title 服務內容
Content of Service 服務日期（年）
Year of Service
 
榮譽或獎項
Honours or Awards

著作名稱
Name of Publications 出版公司
Name of Publisher 出版日期（年）
Year Published

著作
Publications

著作名稱
Name of Publications 出版公司
Name of Publisher 出版日期（年）
Year Published

  
其他資科 (例如: 博士生導師經驗等)
Other Information (For example: Experiences in supervise PhD students, etc.)

我已經閱讀上述資料，並証實無誤。
我明白如上述資料不正確，大學可取消作為博士論文導師的資格。
I have read all information as above is correct and complete.
I understand that the provision of incorrect information may result in the withdrawal of being a PhD dissertation supervisor by the University.#p#分頁標題#e#

_________________________                                _______________________________
申請人簽署                                                              日期
Signed by Applicant                                                Date