The Designated Regional Universities

* Country code: 82-

NO	University	Person in Charge	Tel	Fax	E-mail address
	Chonbuk National University	Ms. Kyounghee Kim	63-270-4757	63-270-2099	[email protected]
	Chonnam National University	Danbi Kang	62-530-1276	62-530-1269	[email protected]
	Chosun University	youshin	62-230-6789	62-232-7355	[email protected]
	Chungbuk National University	Lee Woo Jin	43-261-3841	43-268-2068	[email protected]
	Chungnam National University	Kwak Yujin	42-821-6591	42-823-5875	[email protected] [email protected]
	Daegu University	Sun-nam Han	53-850-5684	53-850-5689	[email protected]
	Dong-A University	Brian Kay	51-200-6442	51-200-6445	[email protected]
	Dongguk University (Gyeongju Campus)	Kim, kyu Hun	54-770-2875	54-770-2385	[email protected]
	Dongseo University	Leo Choi	51-320-2746	51-320-2094	[email protected]
	Gyeongsang National University	Mr. Jun Hyeon JO	55-772-0277	55-772-0269	[email protected]
	Hallym University	Wonkyun No	33-248-1302	33-255-7171	[email protected]
	Handong Global University	Esther KIM	54-260-1806	54-260-1769	[email protected]
	Hannam University	Junghyun Lee	42-629-7923	42-629-7779	[email protected]
Hannam University	Youngsu Yu	42-629-7508	42-629-7838	[email protected]
	HOSEO University	Young Hwan Cho	41-540-9522	41-540-9524	[email protected]
	Jeju National University	Lee Junghyo	64-754-8242	64-754-8247	[email protected]
	Jeonju University (http://www.jj.ac.kr)	Mr. Hyuk-joo Lee	63-220-2887	63-220-2075	[email protected]
Jeonju University (http://www.jj.ac.kr)	Mr. Jong-Sung Park	63-220-2122	63-220-2075	[email protected]
Jeonju University (http://www.jj.ac.kr)	Mr. Sujin Lee	63-220-2195	63-220-2075	[email protected]
Jeonju University (http://www.jj.ac.kr)	Mr. Chung Kwon Lee	63-220-2705	63-220-2075	[email protected]
	Keimyung University	Joonyong Yoon(Mr.)	53-580-6029	53-580-6025	[email protected]
	Kongju National University (http://www.kongju.ac.kr) (http://english.kongju.ac.kr)	Inhaeng Lee Lisa Kim	41-850-8015 41-850-8054	41-850-8903 41-850-8058	[email protected] [email protected]
	Konyang University	Kim Ho-seon	41-730-5135	41-730-5383	[email protected]
	KOREATECH	Seong-hui Lee	41-560-1025	41-560-2509	[email protected]
	Kumoh National Institute Of Technology	Sungmi Lee	54-478-7221	54-478-7222	[email protected]
	Kyungpook National University (http://www.knu.ac.kr http://en.knu.ac.kr/)	Kim Boo Tae	53-950-6092	53-950-6093	[email protected]
	Kyungsung University	Sarah Cho	51-663-4065	51-663-4069	[email protected]
	NAMSEOUL UNIVERSITY	Kim Na Li	41-580-3572~3	41-582-2290	[email protected]
	Pai Chai University (http://www.pcu.ac.kr)	Kichun Do	42-520-5828	42-520-5513	[email protected]
Pai Chai University (http://www.pcu.ac.kr)	Jongseok Park	42-520-5243	42-520-5780	[email protected]
	PUKYONG NATIONAL UNIVERSITY	SANGEUI SHIN	51-629-6846	51-629-6910	[email protected]
	Pusan National University	Hyejung Yang	51-510-3353	51-510-3851	[email protected]
	Semyung University	Shim Yujin	43-649-1185	43-644-7177	[email protected]
	Silla University	Mr. Choi, Jaewon	51-999-5511	51-999-5519	[email protected]
	SOONCHUNHYNAG UNIVERSITY	LIM, JAESAM	41-530-1693	41-530-1381	[email protected]
	Sunmoon University (http://www.sunmoon.ac.kr)	Jae Kyung, Dae	41-530-2033	41-530-2976	[email protected]
	University of Ulsan	Sean Park	52-220-5957	52-224-2061	[email protected]
	Wonkwang University	Lee Hyun Soo (Mr)	63-850-5752	63-850-5753	[email protected]
	Yeungnam Univesity	Kwon, Jagyeong	53-810-7886	53-810-4702	[email protected]

[Appendix 2]

C.G.P.A. Conversion Table

4.0 Scale	4.3 Scale	4.5 Scale	5.0 Scale	100 Points Scale
3.97 ~ 4.0	4.26 ~ 4.3	4.46 ~ 4.5	4.95 ~ 5.00
3.92 ~ 3.96	4.22 ~ 4.25	4.41 ~ 4.45	4.90 ~ 4.94
3.88 ~ 3.91	4.17 ~ 4.21	4.36 ~ 4.40	4.84 ~ 4.89
3.84 ~ 3.87	4.12 ~ 4.16	4.31 ~ 4.35	4.79 ~ 4.83
3.80 ~ 3.83	4.08 ~ 4.11	4.26 ~ 4.30	4.73 ~ 4.78
3.75 ~ 3.79	4.03 ~ 4.07	4.21 ~ 4.25	4.68 ~ 4.72
3.71 ~ 3.74	3.98 ~ 4.02	4.16 ~ 4.20	4.62 ~ 4.67
3.67 ~ 3.70	3.93 ~ 3.97	4.11 ~ 4.15	4.57 ~ 4.61
3.62 ~ 3.66	3.89 ~ 3.92	4.06 ~ 4.10	4.51 ~ 4.56
3.58 ~ 3.61	3.84 ~ 3.88	4.01 ~ 4.05	4.45 ~ 4.50
3.49 ~ 3.57	3.75 ~ 3.83	3.91 ~ 4.00	4.34 ~ 4.44
3.41 ~ 3.48	3.65 ~ 3.74	3.81 ~ 3.90	4.23 ~ 4.33
3.32 ~ 3.40	3.56 ~ 3.64	3.71 ~ 3.80	4.12 ~ 4.22
3.24 ~ 3.31	3.46 ~ 3.55	3.61 ~ 3.70	4.01 ~ 4.11
3.15 ~ 3.23	3.37 ~ 3.45	3.51 ~ 3.60	3.90 ~ 4.00
3.07 ~ 3.14	3.27 ~ 3.36	3.41 ~ 3.50	3.79 ~ 3.89
2.98 ~ 3.06	3.18 ~ 3.26	3.31 ~ 3.40	3.68 ~ 3.78
2.90 ~ 2.97	3.09 ~ 3.17	3.21 ~ 3.30	3.57 ~ 3.67
2.81 ~ 2.89	2.99 ~ 3.08	3.11 ~ 3.20	3.45 ~ 3.56
2.72 ~ 2.80	2.90 ~ 2.98	3.01 ~ 3.10	3.34 ~ 3.44
2.64 ~ 2.71	2.80 ~ 2.89	2.91 ~ 3.00	3.23 ~ 3.33

[Form 1]

2017 ґлЗС№О±№Б¤єОГКГ» їЬ±№АО ЗРєОАеЗР»э Бцїшј­

(Application for 2017 KGSP for an Undergraduate Degree)

∙ Please type or print clearly in English or Korean.

∙ English Name Spelling MUST be exactly the same as in your passport

∙ Please state a date in the following order: year, month and day (ex. January 30, 1994 Ўж 1994/01/30)

БцїшАЪён (ApplicantЎЇs name)
јє (Family name) / АМё§ (Given name) / Middle name
±№Аы(Nationality)		»эівїщАП(Birth-date) (yyyy/mm/dd)
ѕрѕоґЙ·В (Language Proficiency)	ЗС±№ѕо(Korean Proficiency)	Ўа Advanced Ўа Intermediate Ўа Beginner
їµѕо(English Proficiency)	Ўа Advanced Ўа Intermediate Ўа Beginner
јцЗР ИсёБ ґлЗР(Preferred Univ.)
ИсёБ Аь°ш (Preferred Dept.) (Natural Sciences & Engineering)
KOSNET (www.kosnet.go.kr) µо·П [Registration of KOSNET(Korean Language Study on the internet)]	Can you use this site in your country?	Ўа Yes. Ўа No.
If yes, have you registered as a member?	Ўа Yes. Ўа No.

Ўа Checklist (Submission of Documents)

∙ Please put a Ўо in the appropriate box, Type or Print clearly

Required Documents	Original Document	Official Notarized Translation	3 Copied Documents
Yes	No	Yes	No	Yes	No
Ёз Бцїшј­ One Complete Application Form			N/A
Ёи ј­ѕај­ One NIIED Pledge			N/A
Ёй АЪ±вјТ°іј­ One Personal Statement			N/A
Ёк јцЗР°иИ№ј­ One Study Plan			N/A
Ёл ГЯГµј­ 2єО 2 Recommendation Letters (from 2 different recommenders)			N/A
Ём АЪ°Ў°З°­БшґЬј­ One Self Medical Assessment			N/A
Ён °нµоЗР±і Б№ѕчБхёнј­ One Graduation Certificate of High school
Ёо °нµоЗР±і јєАыБхёнј­ One High school Grade Transcripts
Ёп є»АО №Ч єОёр ±№Аы Бхёнј­ One Certificate of Citizenship (Applicant & Parents)
Ёр ЗС±№ѕо ¶ЗґВ їµѕо ґЙ·В °шАО АОБхј­ (ЗШґзАЪёё) One Certificate of Korean or English Proficiency (If applicable)	C. of Korean Proficiency			N/A
C. of English Proficiency			N/A

1/3

Ўа АОАы »зЗЧ (Personal Information)(English Name Spelling MUST be exactly the same as in your passport)

јєён (Full Name)	АЪ±№ѕо (Native language)				ї©±З »зБш (Passport Photo) 3cm Ўї4cm
јє(Family Name)	АМё§(Given Name)	Middle Name
їµѕо* (English)
јє(Family Name)	АМё§(Given Name)	Middle Name
јєє° (Gender)	Ўа Male Ўа Female	»эівїщАП(Date of Birth: yyyy/mm/dd)
°бИҐї©єО(Marital Status)	Ўа Single Ўа Married
Гв»эБц (Place of Birth)	City/Province and Country	ї©±З№шИЈ (Current Passport Number)
±№Аы (Nationality)		ї©±З АЇИї±в°Ј (Passport Expiration date)
АЪЕГ (Home)	БЦјТ (Mailing Address)	ЎШPlease write in ENGLISH ONLY including street address, city, country and postal code.
АьИ­ (Phone)	Country Code / Area Code / Phone Number
ИЮґлАьИ­ (Cell Phone)	___________ Country Code / Cell Phone Number
АМёЮАП (E-mail)
ГвЅЕ°нµоЗР±і (High School)	БЦјТ (Mailing Address)	ЎШPlease write in ENGLISH ONLY including street address, city, country and postal code.
АьИ­ (Phone)	Country Code / Area Code / Phone Number
ЖСЅє (Fax)	Country Code / Area Code / Fax Number

Ўа ѕрѕоґЙ·В (Language Proficiency)

ѕрѕоён (Language)	ЅГЗиён (Title of Test)	јєАы (Score or level)	ЅГЗиАП (Date of Test)	јцБШ(Level)
Beginning	Intermediate	Advanced
ЗС±№ѕо (Korean)
їµѕо (English)

Ўа ЗР·В (Education: including Elementary School): Please list most recent first

АФЗРАП (Entrance Date) ( yyyy/mm/dd)	Б№ѕчАП (Graduation Date) (yyyy/mm/dd)	±в°ьён (Institution)	јТАзБц (Location: city/country)

Ўа °нµоЗР±і јєАы (High School Grades; Only for the semesters attended)

ЗРів (School Year)	1ЗРів (1st year)	2ЗРів (2nd year)	3ЗРів (3rd year)	TOTAL	№йєРАІ (100 percentile)
Grades (G.P.A.)				C.G.P.A.:	/100
RANK				RANK:	/100

Ўа °ЎБ·»зЗЧ (Family Background)

°ь°и (Relationship)	јєён (Name: Family/Given/Middle)	»эівїщАП (Date of Birth)	Бчѕч (Occupation)	°ЕБЦБц (Address: district, city)

Ўа ЗС±№±в°ьїЎј­ јцї© №ЮАє АеЗР±Э (Previous Scholarship Awards Received from Korean institutions)

АеЗР±Эён (Title of Award)	±в°Ј: їїщАП (Period: yyyy/mm/dd)	Бцїш ±в°ь (Institution)
	Ў­
	Ў­

Ўа °ъ°Е ЗС±№їЎј­АЗ °ЕБЦ ¶ЗґВ Гј·щ »зЅЗ (Previous Visits to Korea)

±в°Ј: їїщАП (Period: yyyy/mm/dd)	БцїЄ (City or Region)	ёсАы (Purpose of Stay)	°ЕБЦ ¶ЗґВ Гј·щ°ь·Г±в°ь (Organization Concerned)
Ў­
Ў­

Ўа ГЯГµАО ёнґЬ (List of Recommenders)

јєён (Name)	БцА§ (Position)	јТјУ ±в°ьён (Organization)	АьИ­ (Phone)	АМёЮАП БЦјТ (E-mail Address)

THE ANSWERS I HAVE GIVEN ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. IF MY ANSWERS CONTAIN ANY KIND OF FALSEHOOD, I WILL TAKE ANY LEGAL RESPONSIBILITY.

DATE(yyyy/mm/dd): . .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

[Form 2]

ј­ ѕа ј­

(Pledge)

іЄґВ ґлЗС№О±№ Б¤єОГКГ» ЗРєО АеЗР»эАё·Ој­ ґЩАЅ »зЗЧА» БцЕі °НА» ј­ѕаЗХґПґЩ.

(1) ЗС±№ і» ґлЗРАЗ ЗРДў µоїЎј­ Б¤ЗС ±ФДўїЎ µы¶у ГЦј±А» ґЩЗШј­ ЗРѕч°ъ ї±ёїЎ АьідЗСґЩ.

(2) ЗС±№АЗ »зИёБъј­ё¦ А§№ЭЗПБц ѕКµµ·П ЗаµїЗТ °НАМёз, ёрµз Б¤ДЎИ°µї(Б¤ДЎёсАыАЗ БэИёЎ¤ЅГА§їЎАЗ Вь°Ў, Б¤ДЎ°б»з, Б¤ДЎАыАО ін№®Ў¤ј±ѕрАЗ №ЯЗҐ µо)А» ЗПБц ѕКґВґЩ.

(3) ЗС±№їЎј­ Г¤№«ё¦ Бш °жїм(±№і» °ЕБЦ±в°Ј і») є»АОАМ ГҐАУБц°н єЇБ¦ЗСґЩ.

(4) ЗС±№ѕоїјц №Ч ЗРА§°ъБ¤ јцЗР°ъ °ь·ГЗПї© ±№ёі±№Б¦±іА°їшАМ Б¤ЗС №жД§їЎ ѕо¶°ЗС АМАЗµµ Б¦±вЗПБц ѕК°н µыёҐґЩ.

(5) ±№ёі±№Б¦±іА°їшАМ Б¤ЗС ЗР»зЗаБ¤ Б¶ДЎ»зЗЧїЎ Аы±Ш ЗщБ¶ЗП°н АМё¦ БШјцЗСґЩ.

(6) ЗБ·О±Ч·Ґ їоїµ»у ЗКїдЗП°ЕіЄ Её Б¤єО ±в°ьАЗ їдГ»АМ АЦґВ °жїм є»АОАЗ °іАОБ¤єё (АМё§,

ї¶фГі, јТјУ ЗР±і µо) »зїлїЎ µїАЗЗСґЩ.

»у±в »зЗЧА» А§№ЭЗС °жїм, АеЗР»э Бцїшј­·щАЗ ±вАз»зЗЧАМ ЗгА§»зЅЗ·О ЖЗёнµИ °жїм, ґлЗРїЎј­ ВЎ°иГієР, јєАыєТ·® µо јцЗРґЙ·ВАМ ѕшґЩ°н АОБ¤µИ °жїмїЎґВ АеЗР±Э Бц±ЮА» БЯБц ґзЗПґх¶уµµ АМАЗё¦ Б¦±вЗПБц ѕКА» °НАУА» ј­ѕаЗХґПґЩ.

As a grantee of the 2017 Korean Government scholarship program for an undergraduate course, I pledge to abide by the following rules;

(1) To refrain from violation of university regulations, and to fulfill my obligations as a student to the best of my ability.

(2) To behave in a manner appropriate to the Korean culture and society, and not to participate in any form of political activity (such as organizing a political party, joining a political party, attending political meetings, publishing political articles and declarations, organizing or participating in demonstrations of a political nature, and so on).

(3) To accept responsibility for paying any debts incurred in Korea

(4) To abide by NIIED's policy concerning the Korean language course and the degree course without any objection.

(5) To abide by all of the terms and regulations set by NIIED.

(6) To agree to the use of my personal information (name, contact number, institutions I belong to, etc) when it is needed for the operation of the program or upon the request of other governmental institutions.

If I am proved to have violated any of the above articles, to have made a false statement in my application documents or to have failed to comply with academic standards or the rules of university, I shall accept the decision of NIIED, even though it may include the suspension or revocation of the scholarship.

DATE(yyyy/mm/dd): . .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

[Form 3]

АЪ ±в јТ °і ј­

(Personal Statement)

<БцЅГ№®: АЪ±вјТ°іј­ё¦ 2ЖдАМБц АМі»·О ј­јъЅДАё·О АЫјє(A4, ґЬёйАё·О АЫјє)ЗПµЗ, ѕЖ·Ў і»їлА» ЖчЗФЗПµµ·П ЗПёз, і»їлА» АЯ ѕЛѕЖєј јц АЦµµ·П ЕёАМЗОА» ЗП°ЕіЄ АОјвЗПЅГїА. АМ БцЅГ№®Ає јчБц ИД »иБ¦ЗПЅГїА.>

<Instructions: please write not exceeding 2 pages on an A4 size format, one-sided only. The essay should contain the following things and must be clearly typed or printed in black ink. Please remove the instructions after reading it. >

- Motivations with which you apply for this program

- Personal background in family and education

- Significant experiences you have had; risks you have taken and achievements you have made, persons or events that have had a significant influence on you

- Extracurricular activities such as club activities, community service activities or work experiences

- If applicable, describe awards you have received, publications you have made, or skills you have acquired, etc.

DATE(yyyy/mm/dd): . .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

[Form 4]

јц ЗР °и И№ ј­

(Study Plan)

<БцЅГ№®: ЗС±№ѕо ¶ЗґВ їµѕо·О 3 ЖдАМБц АМі»·О A4 ±Ф°ЭїлБцїЎ ґЬёйАё·О АЫјєЗПЅГїА. јцЗР°иИ№ј­ё¦ АЫјєЗП±в АьїЎ ЗР±і ј±»эґФ°ъ јцЗР ёсАы°ъ °иИ№їЎ ґлЗШ »уАЗЗПЅГ±ж ±ЗАеЗХґПґЩ. АМ БцЅГ№®Ає јчБц ИД »иБ¦ЗПЅГїА.>

<Instructions: Please type or print in Korean or English not exceeding 3 pages on an A4 size format, one-sided only. It is advised that you discuss your academic goals and plans with your teacher before filling out this form. Please remove the instructions after reading it.>

јєён (Name)
Family name / Given name / Middle name
±№Аы (Nationality)		»эівїщАП (Date of Birth:yyyy/mm/dd)
ГвЅЕ°нµоЗР±і (Secondary school attended)		АФЗРАП (Entry Date: yyyy/mm)
Б№ѕчАП (Graduation Date: yyyy/mm)
ЗС±№ѕоґЙ·В (Korean Proficiency)	ЎаAdvanced ЎаIntermediate ЎаBeginner)	їµѕоґЙ·В (English Proficiency)	ЎаAdvanced ЎаIntermediate ЎаBeginner)

јцЗР ИсёБ ґлЗР (Preferred Universities)
ИсёБ Аь°ш (Preferred Departments)

A. ЗС±№АФ±№ Аь ИД ЗРА§°ъБ¤ јцЗРїЎ ЗКїдЗС їЬ±№ѕо(ЗС±№ѕо, їµѕо µо) ґЙ·ВА» Зв»уЅГЕ°±в А§ЗС °иИ№ Study plans to improve foreign languages(Korean, English, etc) required for taking a bachelorЎЇs degree course BEFORE and AFTER you come to Korea.

B. ЗРА§°ъБ¤ јцЗР °иИ№ (ґлЗР №Ч Аь°ш ј±ЕГ АМАЇ, ЗРѕч ёсЗҐїН °иИ№, јцЗР ИД °иИ№А» ±вАзЗП°н, БшЗР ИсёБ ґлЗРє° Аь°шАМ ґЩёҐ °жїмїЎґВ єРё®ЗПї© ±вјъЗПЅГїА) Study plan for a bachelorЎЇs degree course (Please state the reason you choose such universities and departments (or majors), your academic goals, specific plans (including timeline) to achieve them, and future plan after completion of your study. In case that preferred departments (or majors) of the preferred universities are different, please mention about them separately.)

DATE(yyyy/mm/dd): . .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

[Form 5]

Letter of Recommendation

∙ Type or print in English or Korean, not exceeding 2 pages in length.

To be completed by the applicant:

Please fill in your name and other information below. If possible, let your recommender know your study plan in Korea when ask him/her to write this letter. Please note that recommendation letters that are not sealed and signed will not be accepted.

ApplicantЎЇs Name:

Current/Last (High) School:

Date of Birth (yyyy/mm/dd) E-mail:

Desired Field of study	Ўа Humanities & Social Sciences Ўа Natural Sciences & Engineering Ўа Arts and Physical Education
Preferred Universities
Preferred Departments (or Majors)

-----------------------------------------------------------------------------------------------------------------------

To be completed by the recommender:

Your frank and candid appraisal of the applicant will be highly appreciated in the process of selection of Korean Government Scholarship recipients and the admissions to a Korean university. Please make 3 photocopies of the letter after writing it and sign all copies (1 original and 3 photocopied letters) respectively. And please return them sealed in an official envelope which is signed across the back to the applicant; otherwise, they are not valid.

Name: E-mail:

Title, Position and Institution:

Address:

Telephone:

How long have you known the applicant and in what context?

Please assess the applicant's qualities in the evaluation table given below. Rate the applicant compared to other individuals whom you are familiar with.

Classification	Truly Exceptional	Excellent	Very Good	Good	Below Average	N/A
Top 2%	Top 10%	Top 25%	Middle 50%	Lower 25%
Academic Achievement
Future Academic Potential
Integrity
Responsibility/Independence
Creativity/Originality
Communication Skills
Interpersonal skills
Leadership

1/2

Please provide us with comments on the applicantЎЇs performance record, potential, or personal qualities which you believe would be helpful in considering the applicantЎЇs application for the proposed degree program.

DATE(yyyy/mm/dd): . .

NAME OF THE RECOMMENDER SIGNATURE OF THE RECOMMENDER

[Form 6]

АЪ °Ў °З °­ Бш ґЬ ј­

(Self Medical Assessment)

Please provide accurate information for the following questions.

Note: Applicants are not required to undergo an authorized medical exam before passing the 2^nd round of selection; however, all candidates must take a comprehensive medical exam after the 2^nd round of selection (see FORM 7); all grantees must take another comprehensive medical check-up (including HIV, TBPE drug test) after coming into Korea in accordance with the requirements of the Korea Immigration Service and the KGSP. If the results show that any grantee is unfit to study and live overseas, he/she may be disqualified.

QUESTION	YES	NO	EXPLAIN
Ёз When and for what reason did you last consult a physician? (Please explain)
Ёи Have you had any serious ailment, injuries or diseases (high blood pressure, diabetes, tuberculosis, any type of Hepatitis, HIV, etc) in the last five years? (If yes, please explain)
Ёй Have you been hospitalized in the last two years? (If yes, please explain)
Ёк Have you ever been treated by a doctor for any mental, emotional, or anxiety disorder? (If yes, please explain and attach a report from your doctor)
Ёл Have you ever been addicted to any substance? (If yes, please explain)
Ём Do you have any allergies? (If yes, please list them)
Ён Do you have any visual or hearing impairment?
Ёо Do you have any physical disabilities?
Ёп Do you have any cognitive/mental disabilities?
Ёр Are you taking any prescribed medication? (If yes, please explain)
Ёс Are you on a special diet? (If yes, please explain in detail)
Ёт Have you ever suffered from depression? (If yes, please explain)

THE ANSWERS I HAVE GIVEN ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. IF MY ANSWERS CONTAIN ANY KIND OF FALSEHOOD, I WILL TAKE ANY LEGAL RESPONSIBILITY.

Date(yyyy/mm/dd): . .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

[Form 7]

АЗ»з №Я±Ю °З°­ БшґЬј­

(Certificate of Health)

This certificate will be highly appreciated in the process of selection of Korean Government Scholarship recipients and the admissions to a Korean university. Please attach evidential documents which prove that the result of the following examinations is true and correct; otherwise, it is not valid.

Personal Information

Full Name:

Sex:

Date of Birth:

Nationality:

Physical Examination

Blood Pressure: Systolic Diastolic mmHg

Vision: Right 20/ Left 20/ Color Vision

Corrected: Right /15 Left /15

Dental Evaluation: Good ( ) Fair ( ) Poor ( ) Needs Attention ( )

Clinical Evaluation:

Classification	Normal	Abnormal	Classification	Normal	Abnormal
Skin			Heart
Head & Face			Abdomen
Eyes			Rectum
Ears			Genitalia
Mouth & Throat			Extremities
Nose & Sinuses			Back & Spine
Neck			Neurological
Chest & Lungs			Mental
			Other

If Abnormal:

3. Chest X‐ray Examination

Date taken:

Findings:

Laboratory Examination

Hemoglobin: Gm/dl

Urine: S.G. Sugar Micro

Hepatitis B:

Stool for Parasite Oval:

Serological Test for Syphilis:

Other:

In my opinion his/her health condition is;

Excellent ( ) Good ( ) Fair ( ) Poor ( )

This is to certify that the above named applicant has gone through a general medical examination and the findings indicated here are true and correct to the best of my knowledge.

Date			Hospital or Institute
M.D
Signature