2019GLOBAL KOREA SCHOLARSHIP

Korean Government Scholarship Program

Application Guidelinesfor
Undergraduate Degrees
(via Regional Universities for Natural Science & Engineering Majors)

1. Objectives

The Korean Government Scholarship Program for undergraduate degrees is designed to provide international
students with opportunities to study at higher educational institutions in Korea for Bachelor-level degrees, which
will in turncontribute to promoting the international exchange in education and to deepening the mutual
friendship among countries.

2. Total Number of Scholars to Be Selected: 25[from 67 countries]

※ Only those who hold citizenship of the countries below are eligible to apply.
Afghanistan Congo(DRC) Indonesia Mozambique Senegal Uganda

Angola Dominican Republic Iran Myanmar Singapore Ukraine

Azerbaijan Ecuador Japan Nepal Sudan Uruguay

Bangladesh Egypt Jordan Nigeria Sri Lanka Uzbekistan

Bolivia El Salvador Kazakhstan Pakistan Sweden Venezuela

Brazil Equatorial Guinea Kenya Panama Tajikistan Vietnam

Bulgaria Ethiopia Kyrgyzstan Paraguay Tanzania Yemen

Bhutan Fiji Laos Peru Thailand

Cambodia Gabon Malaysia Philippines Timor-Este

Trinidad and
Canada Ghana Mexico Poland
Tobago

Chile Guatemala Mongolia Russia Turkey

Colombia India Morocco Rwanda Turkmenistan

3. Academic Programs: Bachelor’s Degree Program (4 years) after preliminary Korean Language Program (1 year)
 Scholars must take the mandatory Korean language training at a language institution that will be designated
by NIIED. The institution will be specified in the letter of invitation after the announcement of final
successful candidates.

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  Scholars must attain a certain level on TOPIK (Test of Proficiency in Korean) as required by NIIED before the
completion of the one-year Korean language program. Otherwise, scholars are not allowed to proceed to
the degree program.
 Scholars with level 5 or 6 on TOPIK will be exempt from the language program and must begin their
Bachelor’s degree program from Spring 2019.
 Scholars who receive TOPIK level 5 or 6 during the first 6 months of the language program may start their
degree program in the Fall 2019 semester.
4. Available Universities and Fields of Study : 4-Year Bachelor’s degree programs offered at the universities below.

AndongNational Dongguk University, Pukyong National

1 11 21 Jeonju University 31
University Gyeongju University
Busan University of Kangwon National Pusan National
2 12 Dongseo University 22 32
Foreign Studies University University
Chonbuk National Gyeongsang National
3 13 23 Keimyung University 33 Semyung University
University University
Chonnam National Kongju National
4 14 Hallym University 24 34 Silla University
University University
Handong Global Soonchunhyang
5 Chosun University 15 25 KONYANG University 35
University University
Chungbuk National Kumoh National
6 16 Hannam University 26 36 Sunmoon University
University Institute of Tech
Chungnam National Kyungpook National
7 17 Hanseo University 27 37 University of Ulsan
University University
8 Daegu University 18 Hoseo University 28 Kyungsung University 38 Woosuk University

9 DaeJeon University 19 Inje University 29 Namseoul University 39 Yeungnam University

10 Dong-A University 20 Jeju National University 30 Pai Chai University

 Attention! Any degree program which takes more than 4 years to complete is NOT AVAILABLE under this
scholarship program. All applicants cannot choose such degree programs (Examples: medicine, dentistry,
architecture, and pharmacy)
 For more details on the available fields and majors, refer to the “University Information” file that is available
to access in the GKS Notice board, on the Study in Korea website (www.studyinkorea.go.kr). Make sure to
see the “University Information” under the announcement of the Regional University Track. All applicants
must choose a major in the field of natural science or engineering, as listed on the “University
Information”.

5. Qualifications: Prospective applicants must meet all of the following conditions.

(1) CITIZENSHIP: An applicant and his or her parents must be citizens of the country where this scholarship is
offered.
 Attention! Neither the applicant nor the parents should hold the Korean citizenship.

(2) AGE: An applicant must be under age 25 as of March 1, 2019 (Should be born after March, 1, 1994).

(3) HEALTH: An applicant must be in good health, both physically and mentally.
 Those with disabilities, but in good mental and physical health, are eligible to apply.

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  Those with severe illness are NOT ELIGIBLE to apply.

(4) LEVEL OF EDUCATION: An applicant must have graduated or be expected to graduate from a high school as of
March 1, 2019
 Those who have already achieved a Bachelor’s degree or a higher degree are NOT ELIGIBLE to apply.
 Those who have graduated or are expected to graduate from a high school in Korea are NOT ELIGIBLE to
apply.

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 (5) GRADES: An applicant must maintain the overall grade point average (CGPA) equivalent to or higher than any
ONE of the followings:
2.64 on a 4.0 scale;
2.80 on a 4.3 scale;
2.91 on a 4.5 scale;
3.23 on a 5.0 scale; or
Score: 80 points or above on a 100 point scale or be ranked within the top 20% throughout the entire high
school period.[see Appendix 3]
If an applicant’s high school has an evaluation system different from the above scales, see 7-(2)-⑨.

(6) An applicant should never have been awarded with any scholarship programs from Korea for an undergraduate
degree program.

(7) An applicant must have no limitations in travelling abroad

(8) Applicants who have proficiency in the Korean or English language will be given preference.

(9) Descendants of the Korean War veterans will be given preference.

(10) Applicants from low income families or underprivilegedbackgrounds will be given preference.

(11) An applicant is restricted to apply either for the Embassy Track or for the Regional University Track.
 Applicants who apply for both tracks will be automatically disqualified and their applications will be
eliminated.
 Attention! The applicants in the Regional University track must apply for ONLY ONE University. Applicants
who apply for more than one university will be automatically disqualified and their applications will be
eliminated.

6. Scholarship Benefits

(1) Scholarship Period: March 1, 2019 ~ February 29, 2024 (1-year Language + 4-year Degree Program)

(2) Scholarship Benefits

1 Airplane Ticket or Airfare: The scholarship covers an economy class flight with the shortest route between
a scholar’s country and Korea. A one-way ticket to Korea will be offered to each scholar at the beginning of
the scholarship program; another one-way ticket from Korea will be offered for those who complete their
studies under the scholarship program.
2 Monthly Stipend: 800,000 KRW per month

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 3 Tuition: The tuition fee is covered by NIIED and the university entrance fee is covered by the host
university.
4 Settlement Allowance: 200,000 KRW upon arrival
5 Scholarship Completion Grants: 100,000 KRW upon completion of studies only for scholars returning back
to their countries
6 Korean Language Training: The full cost for the 1 year is covered by NIIED and the language institution.
7 Medical Insurance: Scholars are covered by health insurance for major accidents and illnesses during their
scholarship period.
8 Korean Proficiency Grants: Scholars with level 5 or 6 on TOPIK will receive 100,000 KRW won per month
during the degree program.

(3) Notes
1 NIIED does not cover the expenses for the domestic travel both in a scholar’s home country and in Korea.
2 Airfare for entry into Korea will not be provided to a grantee that has been staying in Korea as of the date
of announcement of successful candidates
3 NIIED does not cover flight travel insurance of scholars entering Korea and returning back to their
countries.
4 The medical fee is to be reimbursed through the insurance company to a scholar after he or she pays first.
However, the expense for dental care or chronic disease will not be covered.
5 In case a scholar withdraws from the scholarship program within the first 3 months after entering Korea, he
or she must return all scholarship benefits offered, which includes the entry airfare, settlement allowance,
monthly stipend, tuition, language training fees, Korean proficiency grants, and medical insurance.
6 The return flight ticket and the Scholarship Completion Grants will not be offered for those who withdraw
from the scholarship program.
7 If a student temporarily leaves Korea during the language program, the allowance will not be given during
the period student was absent in Korea. The allowance will not be given if a student’s leave of absence
period exceeds 30days during the degree program.

7. Required Documents

(1) Required Documents: 1 set of the original documents below

1 Completed Application Form (Form 1)
2 NIIED Pledge (Form 2)
3 Personal Statement (Form 3)
4 Study Plan (Form 4)
5 Two Recommendation Letters (Form 5)
Must be from two separate recommenders.

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 The letters must be written by someone who can give in-depth assessment on the applicant’s abilities,
including a high school teacher, principal, or academic advisor.
6 Completed Self Medical Assessment (Form 6)
7 Graduation Certificate of High School
Those who are expected to graduate may submit a provisional graduation certificate of high school.
8 High School Grade Transcript (including a description of the school’s grading system)
9 Certificates of Citizenship of the Applicant and Parents (Examples: abirth certificate, a government-issued
certificate indicating the parent-child relationship, a family register, or parents’passport copies)
10 Awards (Optional)
11 Applicants with certified scores on their proficiency in Korean or in English may be given preference. Some
examples include the following:
 Proficiency in Korea: TOPIK (Test of Proficiency in Korean)
 Proficiency in English: TOEFL, TOEIC, or IELTS Academic (TOEFL ITPs are not acceptable)
12 DD214 or other relevant document to prove the family member’s service at the Korean War)
(applicable to Descendants of the Korean War Veterans Only)
13 Certificate of Health (Form 7, only for candidates who successfully pass the 2nd round of selection)
The certificate of health must be completed and signed by a doctor.
14 Copy of the Applicant’s Passport (only for candidates who successfully pass the 2nd round of selection)

(2) NOTES
1 1 set of the original documents should be placed in a single envelope. Recommendation letters sealed by
the recommenders and submitted with the seals unbroken.
2 Original documents should be submitted. However, should they be available, copies must be
authenticated by the issuing institution, confirming that they are the same with the originals.
3 The applicant’s name on the application form MUST be identical to the applicant’s passport name.
4 If there is any inconsistency in the applicant’s name or birth date on submitted documents, further
evidential document must be submitted as verification.
5 Any applicant, who submits a provisional graduation certificate at the time of applying, must submit his or
her official graduation certificate of high school upon arrival in Korea, no later than March 1, 2019.
6 The application documents must be arranged in the same order as written on the “Checklist” in the FORM
1. Each document may be stapled. However, DO NOT staple the entire application documents altogether,
or put each document in a separate folder.
7 Application form and all other materials should be filled out either in Korean or in English. Any document
issued in languages other than Korean or English MUST include official notarized translations.
8 All documents submitted must be A4 sized. If the document is smaller, attach it to A4 sized paper; if
bigger, fold it to make it A4 sized.
9 The high school grade transcript must contain a description of the school’s grading system. In case the
transcript does not have information on the applicant’s rank or percentile score, an applicant must submit

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 an additional official certificate issued by the high school, confirming that the applicant’s academic
achievement meets the requirement written on 5-(5) above.
10 All documents must be numbered and labeled on the top right corner. (Example. ⑦
Graduati on Certi fi cate of High School)
11 Mailing address should be stated in full including the postal-code
12 Submitted documents will not be returned to the applicant. The applicants are advised to make their own
copies of all application documents.
13 Incomplete or incorrect documents will result in the disqualification of an applicant.

8. Application Deadline: To be decided by the Regional University[see Appendix 1]

 For details on the application deadline and the submission of application documents, applicants should
contact the designated regional universities.
 The first round of selection will be conducted by the universities.
 All applications submitted to NIIED by individual applicants will NOT BE ACCEPTED and will be discarded.

9. Selection Procedures
Period Details
[1stROUND]
 The designated universities announce call for applications.
September, 2018
 Applicants must check the announcement from the universities, including the
deadline.
Universities conduct the first round of selection.
September ~
 Applicants submit the application documents to one of the designated universities.
October
 The universities will conduct the interviews on applicants.
November 1 Universities forward the application documents of the selected candidates to NIIED.
[2NDROUND]
 NIIED conducts the second round of selection through a selection committee.
 NIIED announces the result of the second round of selection on the GKS Notice board
November 16
on www.studyinkorea.go.kr.
 Candidates who pass the second round must submit the passport copy and the
certificate of health (FORM 7) to the university by December 5, 2018.
NIIED announces the final successful candidates on the GKS Notice board on
January 10, 2019
www.studyinkorea.go.kr.
Universityinforms the scholars of their scheduled entry to Korea.
Early February
 Scholars must check their entry flight itinerary and make preparations to enter Korea.
Late February Entry to Korea

※ NOTES
 Applicants must follow the NIIED’s regulations throughout the application procedure.

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  Applicants must write ONE university of their choice in the Forms 1, 4 and 5. Applicants must choose only
ONE department (or major) in the field of natural science or engineering, as listed on the “University
Information”.
 In choosing the preferred university and major, it is advisable to contact the universities in advance for
further information. (See Appendix 1 for the university contact information.)
 Additional documents might be required to be submitted depending on the university or department. If
asked so, the applicants must submit the requested documents to the university.
 Transferring to a different university is NOT allowed after the confirmation of an applicant’s final choice of a
university
 Regardless of university admission, all scholars must achieve the TOPIK level required by NIIED before the
completion of the 1-year Korean language program. Any scholar who fails to do so cannot proceed to his or
her degree.

10. Other Important Information

(1) Entry
1 Scholars must arrive in Korea by late February, 2019. In case a scholar does not enter Korea by the
designated date, his or her scholarship will be canceled.
2 Prior to the arrival, all scholars are advised to study about Korea, Korean language and culture. In
particular, it is advisable that grantees learn as much Korean as possible because most classes at a Korean
university are taught in Korean. Below are some websites that scholars will find useful in preparing their
studies in Korea.

Korean Language Study http://www.sejonghakdang.org

(세종학당->KOSNET 배우기)

Korean Universities http://www.studyinkorea.go.kr

Korean Culture http://korea.net/
Entry & Residence http://immigration.go.kr.

(2) Housing
1 Scholars will live in a university dormitory.
2 The dormitory fee will be deducted out of the monthly stipend by the university.

(3) Cancellation and Temporary Suspension of Scholarship

1 Cancellation of Scholarship: If a scholar is found engaged in any of the following activities during his or
her stay in Korea, the scholarship will be canceled.

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  When any documents of the scholarship application has been found false;
 When a scholar violates the NIIED regulations s/he has pledged to keep;
 When a scholar fails to abide by the guidelines and regulations set by NIIED;
 When a scholar receives a discipline from the university or has participated in political activities.
 When a scholar acts in a way that harms the reputation of the scholarship and/or the relevant
institutions;
 When a scholar fails to reach a TOPIK level required by NIIED within the period of one year language
program;
 When a scholar earns less than 2/3 of the registered credits of a semester;
 When a scholar leaves Korea for the purpose of joining an exchange program in another country;
 When a scholar fails to notify NIIED of re-enrollment without any proper reasons after the end of a
leave of absence;
 When a scholar receives three warnings or more;
 When a scholar forfeits the scholarship.

2 Temporary Suspension of Scholarship

 During the Korean language program, scholars may leave Korea under the language institution’s
approval for up to 2 weeks during the semester and for up to 4 weeks during vacation. For the days of
staying outside of Korea, the monthly allowance will not be given.
 During the degree program, scholars may leave Korea for up to 60 days at a time, under the
university’s approval. For the days exceeding 30 days, the monthly allowance will not be given.

11.Contact

(1) Inquiries on Major & University Admission: 39 Korean Universities(See Appendix 1)

(2) Other Inquiries: NIIED

 Website: www.studyinkorea.go.kr (Scholarships> Government Scholarship > GKS Notice)

 E-mail: [email protected]

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 2019 GLOBAL KOREA SCHOLARSHIP
대한민국정부초청외국인학부장학생모집요강 (지방대추천용)

1. 목적
외국인학생에게대한민국고등교육기관에서수학할기회를부여함으로써국제교육교류촉진및국가간우호증진
을도모하고자함

2. 초청인원 : 25 명 (아래국가의국적을소지한자만프로그램에지원할수있음 )
가나 모로코 수단 우간다 캄보디아 파나마

가봉 모잠비크 스리랑카 우루과이 캐나다 파라과이

과테말라 몽골 스웨덴 우즈베키스탄 케냐 파키스탄

나이지리아 미얀마 싱가포르 우크라이나 콜롬비아 페루

네팔 방글라데시 아제르바이잔 이란 콩고(DRC) 폴란드

도미니카(공) 베네수엘라 아프가니스탄 이집트 키르기스스탄 피지

동티모르 베트남 앙골라 인도 타지키스탄 필리핀

라오스 볼리비아 에콰도르 인도네시아 탄자니아

러시아 부탄 에티오피아 일본 태국

르완다 불가리아 엘살바도르 적도기니 터키

말레이시아 브라질 예멘 칠레 투르크메니스탄

멕시코 세네갈 요르단 카자흐스탄 트리니다드토바고

3. 모집과정 : 1 년이내한국어연수후 4 년제학사과정

※ 한국어연수기관은국립국제교육원이지정함(최종합격자발표후초청장에기재)
※ 1 년한국어연수후일정의 TOPIK 급수를취득하면학위과정으로진학
※ TOPIK 5 급이상을소지한자는한국어연수없이 2019 년 3 월부터학위과정진학
※ 한국입국후 6 개월내 TOPIK 5 급이상을취득한자는 2019 년 9 월학위과정조기진학

4. 지원가능대학및진학가능학과 : 아래제시된지방대학내개설된 4 년제이공계학과

※ 수학연한이 4 년을초과하는학과(의학, 치의학, 건축학과, 약학과등)는제외
※ 자세한정보는 GKS 웹사이트(www.studyinkorea.go.kr)의 The Regional University Information 참조. 지원자
는반드시 The Regional University Information 에등재된지방대학의이공계학과만지원해야함
강원대 공주대 동서대 선문대 우석대 제주대 한림대

건양대 금오공과대 동아대 세명대 울산대 조선대 한서대

경북대 남서울대 배재대 순천향대 인제대 충남대 호서대

경상대 대구대 부경대 신라대 전남대 충북대

경성대 대전대 부산대 안동대 전북대 한남대

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 계명대 동국대(경주) 부산외대 영남대 전주대 한동대

5. 지원자격
(1) 추천대상국국적소유자 (본인및부모)
※ 본인및부모모두한국국적을소유하지않은자이어야함
(2) 2019 년 3 월 1 일현재, 만 25 세미만인자 (1994 년 3 월 1 일이후출생한자)
(3) 한국에서의장기간유학이가능할정도로신체적으로정신적으로건강한자
※ 위 (3)항을충족하는장애인도지원할수있음
※ 질병치료중인자는지원할수없음
(4) 2019 년 3 월 1 일현재고등학교졸업자
※ 한국내고등학교졸업자및학사학위이상소지자는지원할수없음
(5) 고등학교전(全)학년성적평균평점(GPA)이다음의조건중하나이상을충족하는자:
※ 4.0 만점에 2.64 이상
※ 4.3 만점에 2.80 이상
※ 4.5 만점에 2.91 이상
※ 5.0 만점에 3.23 이상
※ 백분율환산점수가 80 점이상혹은성적상위 20% 이내[Appendix 3]의환산표참조
※ 만약지원자의고등학교성적기재방식이위와다른경우, 7-(2)-⑨ 참조
(6) 한국에서동일과정의장학금을받은사실이없는자
(7) 해외여행에결격사유가없는자
(8) 한국어또는영어능력우수자우대
(9) 한국전쟁참전용사후손특별우대
(10) 가정형편등사회,경제적배려대상자우대
(11) 지원자는한수학대학에만지원가능
※ 두개이상의대학에중복지원하면 2 차전형심사대상에서제외

6. 장학금지급
(1) 지급기간: 2019.3.1 ~ 2024.2.29 (한국어연수기간 1 년, 학부과정 4 년)
(2) 지급내역
1 항공권또는항공료: 최초입국시및최종귀국시한국과당해국최단거리국제공항간일반석항공권또는
항공료지급
2 생활비: 매월 800,000 원
3 학비: 입학금과매학기등록금전액지원
4 정착지원금: 최초입국시 200,000 원
5 귀국준비금: 최종귀국시 100,000 원
6 어학연수비: 어학연수비전액지원

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 7 의료보험: 장학기간중질병, 상해, 사고등에대한보험료
8 한국어능력우수자 (TOPIK 5 급이상취득자)에게는학위과정진학후월 100,000 원지급
(3) 유의사항
1 장학생의자국내이동및한국내이동항공료는지원하지않음
2 장학생확정선발통보일기준한국에체류중인자는입국항공료를지급하지않음
3 입국및귀국여행에따른보험료는지원하지않음
4 의료비는장학생이병원또는약국에선납후보험사를통해환불됨 (단, 치과치료및만성질병등에의한
치료비는제외)
5 한국입국후 3 개월이내중도포기한경우, 장학금전액(입국항공료, 정착지원금, 생활비, 한국어연수
비등)을반납하여야함
6 중도포기자에게는귀국항공료와귀국준비금을지원하지않음
7 한국어연수기간중일시출국기간의생활비, 학위과정중학기당 30 일초과일시출국기간의

생활비는지원하지않음

7. 제출서류 : 아래서류원본 1 부
(1) 제출서류
1 지원서 1 부 (Form 1)
2 서약서 (Form 2)
3 자기소개서 (Form 3)
4 수학계획서 (Form 4)
5 추천서 2 부 [Form 5, 추천인 (지도교사, 출신학교장, 지도교수등) 2 명으로부터각 1 부]
6 자가건강진단서 (Form 6)
7 고등학교졸업증명서 1 부또는고등학교졸업예정증명서 1 부 (2019.3.1 현재고등학교졸업자에한함)
8 고등학교성적증명서 1 부 (학교의성적시스템에대한설명서포함)
9 본인및부모의외국국적을확인할수있는증명서 (출생증명서또는가족관계증명서, 부모여권사본등)
10 수상실적등 (해당자에한함)
11 한국어또는영어공인성적증명서 (소지자에한함, 한국어-TOPIK / 영어-TOEIC, TOFLE, IELTS Academic *
기관 TOFLE 등효력이제한적인어학능력시험은인정되지않음)
12 한국전쟁참전용사후손입증서류 (해당자에한함)
13 의사가발급한영문건강증명서 (Form 7, 2 차선발전형통과자에한함)
14 본인여권사본(2 차선발전형통과자에한함)

(2) 유의사항
1 서류원본을봉투에넣어제출하도록함:추천서는개봉하지말고추천자가밀봉해준대로제출하여야함
2 모든서류는원본이어야함. 만약원본을제출할수없는경우, 당초서류발급기관으로부터원본과같다
는확인을받은복사본을제출할수있음
3 지원서의영어성명의철자는반드시여권의것과같아야함

12
 4 지원서류에기재된지원자의성명이나생년월일등이일치하지않을경우, 이를증빙하는추가서류를제
출하여야함
5 고등학교졸업예정자로지원당시고등학교졸업예정증명서를제출한자는한국도착후즉시고등학교
졸업증명서를제출하여야함
6 지원서류는 FORM 1 의체크리스트순으로제출하여야하며, 서류 1 종을스테이플로철할수있으나, 서
류전체를스테이플로철하거나투명파일에하나씩끼워제출하지않도록함
7 신청서를비롯한모든서류는한국어또는영어로작성해야하며, 한국어또는영어로작성되지않은서류
에는반드시공증번역본을첨부하여야함; 공증본은원본앞에정렬함
8 모든서류는 A4 규격으로제출하여야함; 만일서류가 A4 보다작을경우별도 A4 용지에부착하여제출,
A4 보다클경우 A4 규격에맞도록접어서제출하여야함
9 성적증명서에는성적시스템에대한설명서가반드시포함되어야하며, 만약성적증명서에지원자의석
차나비율이표시되어있지않은경우, 지원자의성적이지원자격(상기 5 항-(5))을충족한다는확인서(고
등학교에서발급)를추가제출하여야함
10 모든서류의상단우측에서류명을적어야함
( 예 ) ⑦ Graduati on Certi fi cate of High School
11 주소는우편번호를포함한전체주소를적어야함
12 제출한서류는반환하지않음. 지원자는모든지원서류의복사본을만들어보관하기바람
13 제출서류의기재내용이부정확하거나미비서류가있는경우에는선발대상에서제외함

8. 지원기한 : 추천대학에서정함 [Appendix 1 참조 ]

(1) 프로그램지원및지원서제출등에관한사항은희망대학에문의하여야함
(2) 1 차선발전형을담당하는대학을통하지않은지원서는접수하지않음:지원자가 NIIED 에직접지원할수
없음.

9. 선발절차
일정 선발절차
지방대수학대학 (이하 Univ)은 Univ 장학생후보선발계획발표
~ 2018.9
→ 지원자는 Univ 장학생후보선발계획확인
2018. 9. ~ [1 차선발전형 ]대학장학생후보선발
2018.10 월말 → 지원자는대학의장학생후보선발계획에따라원서제출및면접응시
~ 2018.11.1 Univ 는 1 차선발전형통과자를본원에추천
[2 차선발전형 ] NIIED 장학생선정위원회개최, NIIED 2 차선발전형결과발표
(☞www.studyinkorea.go.kr (NOTICE)
2018.11.16
※ 2 차선발전형통과자는여권사본 , 의사발급건강증명서를 2018.12.5 까지 Univ 에
제출 (Univ 는동서류를 NIIED 에송부)
2019.1.10 NIIED 최종합격자발표

13
 대학은최종합격자에게입국일정통보
2019. 2 월초순
→ 최종합격자는입국일정확인및입국준비
2019.2.25~2.26 한국입국/ 공항픽업(대학)

(1) 유의사항 (대학입학전형관련)

1 지원자는선발절차전반에대한국립국제교육원의방침에따라야함
2 FORM 1 및 FORM 4, FORM 5 에진학희망대학및이공계전공을기재하여야함. 희망대학 1 개, 이공계전
공을선택하여야함[2019GKS-U The Regional University Information 참조 ]
3 진학희망대학및전공을선택하기전에, 해당대학에연락을취하여관련사항을확인하기바람[Appendix
1 참조 ]
4 대학입학전형시, 특정대학또는학과(미술, 음악, 체육등)의방침상추가서류를제출하여야하는경우해
당자는대학의요청에따라추가서류를제출하여야함.
5 최종진학대학을결정한후대학을변경할수없음
6 대학에입학허가를받았다고하더라도한국어연수가종료되기전까지 TOPIK 3 급을취득하지못한경우
학위과정에진학할수없음

10. 기타유의사항
(1) 입국
1 선발된장학생은 2019.2 월말까지입국하여야함. 지정된기일내에입국하지않을경우장학생자격이취
소됨
2 장학생은입국전에한국및한국문화등의사전연구가필요함. 특히대부분대학의수업이한국어로진행
되므로한국어를사전학습하여주시기바람.
▪ 한국어학습 http://www.sejonghakdang.org(세종학당->KOSNET 배우
기)
▪ 한국내대학 http://www.studyinkorea.go.kr
▪ 한국문화이해 http://korea.net
▪ 입국및체류 http://immigration.go.kr

(2) 숙소
1 장학생은수학대학의기숙사에서생활하게됨
2 기숙사비는본원에서지원하는생활비에서공제함
(3) 장학금지급중단및일시정지
1 다음의경우에는장학생자격을상실하고장학금지급을중단함
- 지원서류가허위로작성되었거나사실과다른것으로드러났을때
- 국립국제교육원에서약한사항을위반했을때
- 국립국제교육원이정한학사행정조치사항에따르지아니한때
- 수학기관으로부터징계처분을받았거나정치활동을한경우

14
 - 장학생으로서품위를손상시키는행동을한때
- 한국어연수종료전까지 NIIED 가정한일정 TOPIK 급수에도달하지못한때
- 무단수학중단으로수학과정재학중해당학기에수강신청한과목학점의 2/3 이상을취득하지못한
때
- 외국대학과의학점교류등으로출신국또는제 3 국으로출국한때
- 휴학기간종료후정당한사유없이복학원서를제출하지않을때
- 경고 3 회이상받은때
- 중도포기했을때
2 다음의경우에는장학금지급을일시정지함
- 한국어연수기간중에장학생은소속한국어연수기관의허가를받아학기중에는최대 2 주, 방학중
에는방학기간범위내최대 4 주일시출국할수있음. 그러나일시출국기간의생활비는지급하지아
니함
- 수학과정중에장학생은소속대학의허가를받아 1 회 60 일을출국할수있음. 그러나방학을포함하
여학기당 30 일을초과하여일시출국하는경우, 30 일초과기간의생활비는지급하지아니함

11. 문의처
(1) 프로그램지원및지원서제출: 수학가능대학 (94 개대학)
[Appendix 1 참조 ]
(2) 기타
- http://www.studyinkorea.go.kr [Scholarships > Government Scholarship > GKS Notice]
- 이메일상담 :[email protected]

15
[Appendix 1-Contact Points-Application for University Admission]

The Designated Regional Universities

NO University Personin Charge Tel Fax E-mail address

1 Andong National University HeoYeonghui 82-54-820-7102 82 54-820-7108 [email protected]

2 Busan University of Foreign Studies Kim Tae-jin 82-51-509-5329 82 51 509 5340 [email protected]

3 Chonbuk National University Lee Se Hoon 82-63-270-4888 82-63-270-2099 [email protected]

4 Chonnam National University Eunhui CHA 82-62-530-1277 82-62-530-1269 [email protected]

5 Chosun University Sung-woo Lee 82-62-230-6498 82-62-608-5229 [email protected]

6 Chungbuk National University Jaeseung Lee 82-43-261-3293 82-43-268-2068 [email protected]

7 Chungnam National University KwakYujin 82-42-821-6591 82-42-823-5875 [email protected]

8 Daegu University LEE, SEUNG CHUL 82-53-850-5686 82-53-850-5689 [email protected]

9 DaeJeon University Samyoul Jung 82-42-280-2124 82-24-282-8533 [email protected]

10 Dong-A University Brian Kay 82-51-200-6442 82-51-200-6445 [email protected]

[email protected],
11 Dongguk University, Gyeongju Choi, Wonjung 82-54-770-2882 82-54-770-2385
[email protected]

12 Dongseo University Lee Yoonseo 82-51-320-2746 82-51-320-2094 [email protected]

13 Gyeongsang National University Mr. Jun Hyeon JO 82-55-772-0277 82-55-772-0269 [email protected]

14 Hallym University Yoon Jung-hwan 82-33-248-1346 82-33-248-1349 [email protected]

15 Handong Global University Esther KIM 82-54-260-1806 82-54-260-1769 [email protected]

16 Hannam University Choo Jong-sul 82-42-629-7506 82-42-629-7838 [email protected]

Kim Jin Woo 82-41-660-1304 82-41-660-1707 [email protected]

17 Hanseo University Lee Young Rok 82-41-660-1705 82-41-660-1707 [email protected]

Kang Rhyung 82-41-660-1706 82-41-660-1707 [email protected]

18 Hoseo University Chanmi Moon 82-41-540-9522 82-41-540-9524 [email protected]

19 Inje University PARK CHO RONG 82-55-3203605 82-55-3335208 [email protected]

20 Jeju National University Pyojeong Kim 82-64-754-8241 82-64-754-0563 [email protected]

Mr. Hyukjoo Lee 82-63-220-2887 82-63-220-2075 [email protected]

Mr. Jongsung Park 82-63-220-2122 82-63-220-2075 [email protected]

21 Jeonju University
Mr. Jae-hyun Kim 82-63-220-3285 82-63-220-2075 [email protected]

Mr. Chungkwon Lee 82-63-220-2705 82-63-220-2075 [email protected]

82-33-570-
OH JOO HYEON 82-33-570-6308 [email protected]
22 Kangwon National University 6891/6892

AHN MOON SEOP 82-33-250-7194 82-33-259-5522 [email protected]

23 Keimyung University Jinmyoung Kim(Mr.) 82-53-580-6027 82-53-580-6025 [email protected]

24 Kongju National University Park, Jinyeo 82-41-850-8054 82-41-850-8058 [email protected]

16
25 KONYANG University KIM HOSEON 82-41-730-5135 82-41-730-5383 [email protected]

Kumoh National Institute of

26 Minah Kim 82-54-478-7216 82-54-478-7222 [email protected]
Technology

27 Kyungpook National University Kim Boo Tae 82-53-950-2433 82-53-950-2419 [email protected]

28 Kyungsung University Sarah Cho 82-51-663-4065 82-51-663-4069 [email protected]

Seomoon Chan 82-41-580-2774 82-41-582-2290 [email protected]

29 Namseoul University
Nari Kim 82-41-580-3572~3 82-41-582-2290 [email protected]

82-70-4850-
Pyung-rak Choi 82-80-527-8272 [email protected]
8305
30 Pai Chai University
82-70-4850-
Ryan Jongseok Park 82-42-520-5243 [email protected]
8306

31 Pukyong National University Jungeun Kim 82-51-629-6846 82-51-629-6910 [email protected]

32 Pusan National University Youngju Kang 82-51-510-3636 82-51-510-3851 [email protected]

33 Semyung University Yujin Shim 82-43-649-1185 82-43-644-7177 [email protected]

34 Silla University Mr. Yun Inseog 82-51-999-5512 82-51-999-5519 [email protected]

35 SOONCHUNHYANG UNIVERSITY LIM, JAESAM 82-41-530-1693 82-41-530-1381 [email protected]

36 Sunmoon University Kyung Min, Lee 82-41-530-2032 82-41-530-2976 [email protected]

37 University of Ulsan Sean Park 82-52-220-5957 82-52-224-2061 [email protected]

38 Woosuk University Inhwa KIM 82-63-290-1078 82-63-290-1122 [email protected]

39 Yeungnam University Sunho Lee 82-53-810-7886 82-53-810-4702 [email protected]

17
[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 ~ 5.00 100

3.92 ~ 3.96 4.22 ~ 4.25 4.41 ~ 4.45 4.90 ~ 4.94 99

3.88 ~ 3.91 4.17 ~ 4.21 4.36 ~ 4.40 4.84 ~ 4.89 98

3.84 ~ 3.87 4.12 ~ 4.16 4.31 ~ 4.35 4.79 ~ 4.83 97

3.80 ~ 3.83 4.08 ~ 4.11 4.26 ~ 4.30 4.73 ~ 4.78 96

3.75 ~ 3.79 4.03 ~ 4.07 4.21 ~ 4.25 4.68 ~ 4.72 95

3.71 ~ 3.74 3.98 ~ 4.02 4.16 ~ 4.20 4.62 ~ 4.67 94

3.67 ~ 3.70 3.93 ~ 3.97 4.11 ~ 4.15 4.57 ~ 4.61 93

3.62 ~ 3.66 3.89 ~ 3.92 4.06 ~ 4.10 4.51 ~ 4.56 92

3.58 ~ 3.61 3.84 ~ 3.88 4.01 ~ 4.05 4.45 ~ 4.50 91

3.49 ~ 3.57 3.75 ~ 3.83 3.91 ~ 4.00 4.34 ~ 4.44 90

3.41 ~ 3.48 3.65 ~ 3.74 3.81 ~ 3.90 4.23 ~ 4.33 89

3.32 ~ 3.40 3.56 ~ 3.64 3.71 ~ 3.80 4.12 ~ 4.22 88

3.24 ~ 3.31 3.46 ~ 3.55 3.61 ~ 3.70 4.01 ~ 4.11 87

3.15 ~ 3.23 3.37 ~ 3.45 3.51 ~ 3.60 3.90 ~ 4.00 86

3.07 ~ 3.14 3.27 ~ 3.36 3.41 ~ 3.50 3.79 ~ 3.89 85

2.98 ~ 3.06 3.18 ~ 3.26 3.31 ~ 3.40 3.68 ~ 3.78 84

2.90 ~ 2.97 3.09 ~ 3.17 3.21 ~ 3.30 3.57 ~ 3.67 83

2.81 ~ 2.89 2.99 ~ 3.08 3.11 ~ 3.20 3.45 ~ 3.56 82

2.72 ~ 2.80 2.90 ~ 2.98 3.01 ~ 3.10 3.34 ~ 3.44 81

2.64 ~ 2.71 2.80 ~ 2.89 2.91 ~ 3.00 3.23 ~ 3.33 80

[Form 1]

2019 대한민국정부초청외국인학부장학생지원서

18
 (Application for 2019GKS for an Undergraduate Degree)
지방대이공계전형 / via Regional Universities for Natural Science & Engineering Majors

∙ 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, 1995 → 1995/01/30)

지원자명
(Applicant’s name) 성 (Family name) / 이름 (Given name) / Middle name

생년월일(Birth-date)
국적(Nationality) Indonesian 2001/11/04
(yyyy/mm/dd)

언어능력 한국어(Korean Proficiency) □ Advanced □ Intermediate □ Beginner

(Language Proficiency) 영어(English Proficiency) □ Advanced □ Intermediate □ Beginner

수학희망대학(Preferred Univ.)

희망전공(Preferred Dept.)
(Natural Sciences & Engineering)

□ Checklist (Submission of Documents)

∙Please put a √ in the appropriate box, Type or Print clearly
Official
Original
Notarized
Required Documents Document
Translation

Yes No Yes No

1 지원서 One Complete Application Form N/A

2 서약서 One NIIED Pledge N/A

3 자기소개서 One Personal Statement N/A

4 수학계획서 One Study Plan N/A

5 추천서 2 부 2 Recommendation Letters (from 2 different recommenders) N/A

6 자가건강진단서 O ne Se l f Me di cal Asse ssm e nt N/A

7 고등학교졸업증명서 One Graduation Certificate of High school

8 고등학교성적증명서 One High school Grade Transcripts

9 본인및부모국적증명서 One Certificate of Citizenship (Applicant & Parents)

10 수상실적 (해당자만) Awards (Optional) yes

11 한국어또는영어능력공인인증서 ( 해당자만 ) C. of Korean Proficiency N/A

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One Certificate of Korean or English Proficiency(If applicable) C. of English Proficiency N/A

13 한국전쟁참전용사후손입증서류 (해당자에한함)

Korean War Veterans Documents (If applicable)

1/3

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□ 인적사항 (Personal Information) (English Name Spelling MUST be exactly the same as in your passport)

자국어 Alvisca nadya bella

(Native
성명 성(Family Name) 이름(Given Name) Middle Name
language) 여권사진
(Full Name)
영어* (Passport Photo)

(English) 성(Family Name) 이름(Given Name) Middle Name 3cm ×4cm

성별 □ Male 생년월일(Date of Birth: yyyy/mm/dd)

(Gender) □ Female 결혼여부(Marital Status) □ Single □ Married

출생지 Kediri/east java Indonesia 여권번호

(Place of Birth) City/Province and Country (Current Passport Number)

국적 여권유효기간
(Nationality) (Passport Expiration date)

주소 ※Please write in ENGLISH ONLY including street address, city, country and postal code.
(Mailing

Address)

전화
자택
(Phone) Country Code / Area Code / Phone Number
(Home)
휴대전화 ___________________________________________________________________________

(Cell Phone) Country Code / Cell Phone Number

이메일
[email protected]
(E-mail)

주소 ※Please write in ENGLISH ONLY including street address, city, country and postal code.
(Mailing

Address)

출신고등학교 전화
(High School) (Phone) Country Code / Area Code / Phone Number

팩스
(Fax) Country Code / Area Code / Fax Number

□ 언어능력 (Language Proficiency)

수준(Level)
언어명 시험명 성적 시험일
Intermediat Advance
(Language) (Title of Test) (Score or level) (Date of Test) Beginning
e d

한국어 (Korean)

영어 (English) TOEIC 900 AGUSTUS YES

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□ 학력 (Education: including Elementary School): Please list most recent first
입학일 졸업일
기관명 소재지
(Entrance Date) (Graduation Date)
(Institution) (Location: city/country)
( yyyy/mm/dd) (yyyy/mm/dd)

2/3

□ 고등학교성적 (High School Grades; Only for the semesters attended)

학년 백분율
1 학년(1st year) 2 학년(2nd year) 3 학년(3rd year) TOTAL
(School Year) (100 percentile)

Grades (G.P.A.) 84 C.G.P.A.:86.7 /100

RANK 3 1 1 RANK: /100

□ 가족사항 (Family Background)

관계 성명 생년월일 직업 거주지
(Relationship) (Name: Family/Given/Middle) (Date of Birth) (Occupation) (Address: district, city)

SOLDIER
FATHER MAHMUDI 06/06/1966
PENSIUN

IWAN RESTU DEWANGGA

□ 한국기관에서수여받은장학금 (Previous Scholarship Awards Received from Korean institutions)

장학금명 기간: 연월일 지원기관
(Title of Award) (Period: yyyy/mm/dd) (Institution)

□ 과거한국에서의거주또는체류사실 (Previous Visits to Korea)

기간: 연월일 지역 목적 거주또는체류관련기관
(Period: yyyy/mm/dd) (City or Region) (Purpose of Stay) (Organization Concerned)

22
□ 추천인명단 (List of Recommenders)
성명 지위 소속기관명 전화 이메일주소
(Name) (Position) (Organization) (Phone) (E-mail Address)

ISLAMIC HIGH SCHOOL OF 1

HARI WIYANTO HEADMASTER
KEDIRI

SUJONO HEAD OF CLASS

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

3/3

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[Form 2]

GKS Applicant Pledge

As an applicant for the 2019Global Korea Scholarship (GKS) Program for Undergraduate
Degree, I pledge to abide by the followings;

 Please read each article and check the box below

(1) All documents I submitted to NIIED are true; □

(2) I will abide by all the Korean laws and ordinances; □

(3) I will respect and uphold the values of the Korean culture and society; □

(4) I will fulfill my responsibilities as a GKS scholar to the best of my abilities; □

(5) I will not participate in any form of political activities; □

(such as organizing or joining a political party, attending political meetings, publishing articles and
declarations, and organizing or participating in political demonstrations)

(6) I will maintain financial integrity at a personal level; □

(7) I accept NIIED’s decision concerning the undergraduate degree program and the
Korean language program; □

(8) I understand it is not permitted to change the university, either for the Korean language
program or for the degree program; □

(9) I will observe the regulations of NIIED and the university; and □

(10)I give permission to NIIED to use my personal information for GKS □

I confirm that I read all of the above conditions. I also understand that the violation of any one

24
of the above might result in the suspension or cancellation of the scholarship.

DATE(yyyy/mm/dd): .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

25
[Form 3]

자기소개서
(Personal Statement)

<지시문: 자기소개서를 2 페이지이내로서술식으로작성(A4, 단면으로작성)하되, 아래내용을포함하도록하며, 내용을잘알

아볼수있도록타이핑을하거나인쇄하시오. 이지시문은숙지후삭제하시오.>
<Instructions: Please write no more than 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

- Family and Education background
- 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): . .

26
NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

27
[Form 4]

수학계획서
(Study Plan)

<지시문: 한국어또는영어로 3 페이지이내로 A4 규격용지에단면으로작성하시오. 수학계획서를작성하기전에학교선생님

과수학목적과계획에대해상의하시길권장합니다.이지시문은숙지후삭제하시오.>
<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.>

성명

(Name) Family name / Given name / Middle name

국적 생년월일

(Nationality) (Date of Birth:yyyy/mm/dd)

입학일
출신고등학교
(Entry Date: yyyy/mm)
(Secondary school
졸업일
attended)
(Graduation Date: yyyy/mm)

한국어능력 영어능력
□Advanced □Intermediate □Beginner) □Advanced □Intermediate □Beginner)
(Korean Proficiency) (English Proficiency)

수학희망대학

(Preferred Universities)

희망전공

(Preferred Departments)

A. 한국입국전후학위과정수학에필요한외국어(한국어, 영어등) 능력을향상시키기위한계획

Study plansto improve foreign languages(Korean, English, etc) required for taking a bachelor’s degree course

BEFOREand AFTER you come to Korea.

28
B. 학위과정수학계획 (대학및전공선택이유, 학업목표와계획,수학후계획을기재하고, 진학희망대학별전공이다른경우에는분리하

여기술하시오)

Study plan for a bachelor’s degree course (Please state the reason you choose such university and department (or major),

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.)

29
 DATE(yyyy/mm/dd): . .

NAME OF THE APPLICANT SIGNATURE OF THE APPLICANT

30
[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.Pleasenote that recommendation letters that are not sealed and signed will not be accepted.

Applicant’s Name:
Current/Last (High) School:
Date of Birth (yyyy/mm/dd) E-mail:

Desired Field of study □ Humanities & Social Sciences □ Natural Sciences & Engineering □ 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 seal your letter of recommendation in an official envelope

and sign across the back flap upon completion.

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.
Truly
Excellent Very Good Good Below Average
Classification Exceptional N/A

Top 2% Top 10% Top 25% Middle 50% Lower 25%

Academic Achievement

Future Academic Potential

Integrity

Responsibility/Independence

Creativity/Originality

Communication Skills

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 Interpersonal skills

Leadership

1/2

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

32
 DATE(yyyy/mm/dd): . .

NAME OF THE RECOMMENDER SIGNATURE OF THE RECOMMENDER

33
[Form 6]

자가건강진단서
(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 TBPE
drug test) after coming into Korea in accordance with the requirements of the Korea Immigration Service
and the GKS.If the results show that any grantee is unfit to study and live overseas, he/she may be
disqualified.

QUESTION YES NO EXPLAIN

1 When and for what reason did you last consult a

physician? (Please explain)

2 Have you had any serious ailment, injuries or diseases

(high blood pressure, diabetes, tuberculosis, any type of
Hepatitis, etc.) in the last five years? (If yes, please
explain)

3 Have you been hospitalized in the last two years?

(If yes, please explain)

4 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)

5 Have you ever been addicted to any substance?

(If yes, please explain)

6 Do you have any allergies? (If yes, please list them)

7 Do you have any visual or hearing impairment?

8 Do you have any physical disabilities?

9 Do you have any cognitive/mental disabilities?

10 Are you taking any prescribed medication?

(If yes, please explain)

11 Are you on a special diet?

(If yes, please explain in detail)

34
 12 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

[Form7]

의사발급건강진단서
(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 documentswhich prove that the result of the following
examinations is true and correct; otherwise, it is not valid.

1. Personal Information
Full Name:
Sex:
Date of Birth:
Nationality:

2. 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

35
 Mouth & Throat Extremities
Nose & Sinuses Back & Spine
Neck Neurological
Chest & Lungs Mental
Other

If Abnormal:

3. Chest X-ray Examination

Date taken:
Findings:

4. 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

36