1. Healthcare

APPLICATION FORM
BA in Language and Culture (International Program)
Faculty of Arts, Chulalongkorn University
FOR ACADEMIC YEAR 2015

PLEASE USE BLOCK LETTERS.
FIRST NAME: _________________________________
LAST NAME: _________________________________
Please attach your
FULL NAME (IN THAI): _________________________
photograph.
This application form has ten pages and it is divided into six parts. Please read the instructions
carefully. After completing the form, please affix your signature on the last page before submitting
your application. The application deadline for our 2015 academic year is January 30, 2015.
Part 1
DOCUMENT CHECK LIST
Part II
PERSONAL INFORMATION
Part III
ACADEMIC PROFILE
Part IV
TEST SCORES
Part V
LANGUAGE SKILLS AND OTHER ACHIEVEMENTS
Part VI
STATEMENT OF PURPOSE
BALAC Application Form 2015
Faculty of Arts, Chulalongkorn University
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PART I
DOCUMENT CHECK LIST
Please tick  in the box provided to ensure that you have enclosed the required documents.
DOCUMENTS
FOR
APPLICANT
FOR
OFFICE USE
1. COMPLETED APPLICATION
FORM AND YOUR STATEMENT
OF PURPOSE WITH YOUR
AFFIXED SIGNATURE
2. COPY OF IDENTITY CARD OR
PASSPORT
3. OFFICIAL HIGH SCHOOL
TRANSCRIPT*
4. ORIGINAL (OR CERTIFIED
COPIES OF) ENGLISH
PROFICIENCY TEST SCORES
(TOEFL, IELTS, OR CU-TEP)
5. ORIGINAL (OR CERTIFIED
COPIES OF) APTITUTE TEST
SCORES (SAT I, CU-AAT, OR
ACT)
6. TWO ONE-INCH PHOTOS WITH
YOUR NAME WRITTEN ON THE
BACK (ONE OF WHICH IS
AFFIXED TO THE FRONT PAGE
OF THIS APPLICATION FORM)
7. 1000 BAHT NON-REFUNDABLE
APPLICATION FEE
*Successful applicants who have not yet finished secondary studies must submit their high school
certificate or the equivalent by August 28, 2015 Otherwise they will forfeit the right to enter
Chulalongkorn University.
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Faculty of Arts, Chulalongkorn University
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PART II
PERSONAL INFORMATION
IDENTIFICATION CARD NO. ____________________________________________
PASSPORT NO. (FOR NON-THAI APPLICANTS) ______________________________
PLACE OF BIRTH (CITY, COUNTRY) ______________________________________
DATE OF BIRTH (DD/MM/YY) ____________________________________________
HOME COUNTRY ___________________________NATIONALITY _____________
PERMANENT ADDRESS _________________________________________________
____________________________________________________________________
____________________________________________________________________
TELEPHONE NO. _______________________ FAX NO. ______________________
EMAIL ________________________________ MOBILE _______________________
MAILING ADDRESS (IF DIFFERENT FROM ABOVE) ____________________________
____________________________________________________________________
____________________________________________________________________
FATHER’S NAME ______________________________________________________
OCCUPATION/POSITION _______________________________________________
COMPANY/BUSINESS NAME _____________________________________________
TELEPHONE NO. ______________________ MOBILE ________________________
MOTHER’S NAME
____________________________________________________________________
OCCUPATION/POSITION _______________________________________________
COMPANY/BUSINESS NAME _____________________________________________
TELEPHONE NO. _______________________________ MOBILE _______________
BALAC Application Form 2015
Faculty of Arts, Chulalongkorn University
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PART III
ACADEMIC PROFILE
A. HIGH SCHOOL DETAILS
HIGH SCHOOL NAME _________________________________________________
CITY/STATE/COUNTRY ________________________________________________
SCHOOL TYPE:
 THAI SCHOOL
 INTERNATIONAL SCHOOL
 THAI CURRICULUM
 AMERICAN CURRICULUM
 ENGLISH/BILINGUAL PROGRAM
 BRITISH CURRICULUM
 IB
 NEW ZEALAND
 AUSTRALIA
 OTHER, PLEASE STATE
_____________________
(EXPECTED) DATE OF COMPLETION ______________________________________
CUMULATIVE GPAs FROM MATHAYOM 4 -6 (OR FROM GRADE 10 TO 12) ON 4.0
SCALE OR EQUIVALENT: _____________
PLEASE INDICATE YOUR RANKING IN CLASS:
 TOP 5%
 TOP 10%
BALAC Application Form 2015
Faculty of Arts, Chulalongkorn University
 TOP 20%
 OTHER OR N/A
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B. EDUCATIONAL HISTORY
PLEASE GIVE THE NAME(S) OF OTHER SCHOOL(S) YOU HAVE ATTENDED
(EXCLUDING YOUR HIGH SCHOOL DETAILS GIVEN IN SECTION A).
SCHOOL NAME/COUNTRY
DATES ATTENDED
LEVEL
_________________________ _______________ ____________
_________________________ _______________ ____________
_________________________ _______________ ____________
_________________________ _______________ ____________
_________________________ _______________ ____________
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Faculty of Arts, Chulalongkorn University
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PART IV
TEST SCORES
LANGUAGE PROFICIENCY TESTS:
 TOEFL
 INTERNET-BASED
TOTAL SCORE: _______
 PAPER-BASED
TOTAL SCORE: _______
 COMPUTER-BASED
TOTAL SCORE: _______
 IELTS
OVERALL BAND: _______
 CU-TEP
TOTAL SCORE: _______
APTITUDE TESTS:
 SAT
CRITICAL READING SCORE: _______
 CU-AAT
VERBAL SCORE: _______
 ACT
ENGLISH SCORE: _______
*Please be reminded that these test results remain valid only two years after the test dates.
*Please submit the original or certified copies of these test results along with this application form.
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Faculty of Arts, Chulalongkorn University
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PART V
LANGUAGE SKILLS & OTHER
ACHIEVEMENTS
NATIVE LANGUAGE _______________________
OTHER LANGUAGES AND LEVELS OF COMMAND (VERY GOOD/GOOD/FAIR)
LANGUAGE(S)
WRITING
READING SPEAKING/LISTENING
1. ____________
_________ ________ ___________
2. ____________
_________ ________ ___________
3. ____________
_________ ________ ___________
4. ____________
_________ ________ ___________
IF ADMITTED, YOUR CHOICE OF MINOR LANGUAGE SUBJECT WOULD BE (PLEASE
LIST IN THE ORDER OF PREFERENCE FROM 1 TO 8):
CHINESE ___
JAPANESE ___
GERMAN ___
SPANISH ____
KOREAN ___
RUSSIAN ____
FRENCH ___
ITALIAN ____
IF WE ARE UNABLE TO ACCOMMODATE YOUR TOP CHOICE OF MINOR
LANGUAGE SUBJECT, WOULD YOU STILL BE INTERESTED IN STUDYING IN THIS
PROGRAM?
 YES
 NO
 OTHER, PLEASE STATE ____________________
*This year there will be a maximum of four language choices available. All languages will start at
the beginner’s level.
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Faculty of Arts, Chulalongkorn University
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HAVE YOU RECEIVED ANY AWARDS OR SCHOLARSHIPS? IF YES, PLEASE GIVE
DETAILS.
AWARDS/SCHOLARSHIPS
DATES RECEIVED
_______________________________ __________________
_______________________________ __________________
_______________________________ __________________
_______________________________ __________________
WHILE AT SCHOOL, HAVE YOU PARTICIPATED IN ANY EXTRACURRICULAR
ACTIVITIES? IF YES, PLEASE GIVE DETAILS.
EXTRACURRICULAR ACTIVITIES
DATES
_______________________________ __________________
_______________________________ __________________
_______________________________ __________________
_______________________________ __________________
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Faculty of Arts, Chulalongkorn University
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PART VI
STATEMENT OF PURPOSE
Please write your answer in the space provided.
WHY ARE YOU INTERESTED IN OUR PROGRAM? WHAT DO YOU EXPECT TO GAIN
FROM OUR PROGRAM?
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Faculty of Arts, Chulalongkorn University
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I hereby certify that the information on this application is complete, accurate, and
true. I agree to abide by the policies and regulations of Chulalongkorn University.
I also understand that the decision by the BA in Language and Culture Program
Admission Committee and/or Chulalongkorn University for admission and/or
enrollment is final.
Signature _____________________________ Date ____________________
(
BALAC Application Form 2015
Faculty of Arts, Chulalongkorn University
)
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