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University Entrance Committee for Mainland Chinese StudentsNo. 1, Nan-Tai Street, Yongkang Dist., Tainan City 71005, TaiwanE-mail：rusen@mail.stust.edu.tw WEB：http://rusen.stust.edu.twTEL：+886-6-2435163 FAX：+886-6-2435165

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https://www.immigration.gov.tw/ct_cert.asp?xItem=1101391&ctNode=32595&

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Letter of Attorney /

I, the client, who want to apply for for

Mr./Ms. , am unable to present the application in person and

have commissioned Mr./Ms. as my agent to deliver

the application with his/her and my original I.D. certificates to your agency.

http://www.immigration.gov.tw/

The above statement is addressed to the National Immigration Agency http://www.immigration.gov.tw/

of the Ministry of the Interior.

Name of client Commission date

(In case an immigration business or class A travel agency acts as the agent, its corporate seal shall be set here)

Address of deliverer

Please paste the front copy of the agent’s photo ID certificate

Please paste the back copy of the agent’s photo ID certificate

In case the application is for the Entry & Exit Date Certificate , please paste the front

copy of the client’s photo ID certificate.

附件7

Letter of Attorney /

I, the client, who want to apply for for

Mr./Ms. , am unable to present the application in person and

have commissioned Mr./Ms. as my agent to deliver

the application with his/her and my original I.D. certificates to your agency.

http://www.immigration.gov.tw/

The above statement is addressed to the National Immigration Agency http://www.immigration.gov.tw/

of the Ministry of the Interior.

Name of client Commission date

(In case an immigration business or class A travel agency acts as the agent, its corporate seal shall be set here)

Address of deliverer

Please paste the front copy of the agent’s photo ID certificate

Please paste the back copy of the agent’s photo ID certificate

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Hospital’sLogo

ITEMS REQUIRED FOR HEALTH CERTIFICATE Form BHospital’s Name, Address, Tel, FAX Date of Examination

( BASIC DATA)

(LABORATORY EXAMINATIONS)

A. HIV Serological Test for HIV AntibodyPositive Negative Indeterminate

. Screening Test EIA PA Others ______________ . Confirmatory Test Western Blot Others ______________

15 (Not required for children under 15 year of age)

B. X Chest -Ray for Tuberculosis X (Findings)

(Results)(Passed) (TB Suspect) ( Pending) (Failed)

() (Those who are determined to be TB suspects or have a

pending diagnosis by the designated hospital in Taiwan must visit the referred institution for further evaluation.)

12 (Not required for pregnant women or children under 12 years of age)

C. Stool examination for parasites includes Entameba histolytica etc. (centrifugal concentration method)

( Positive, Species ) ______________________ Negative(Other parasites that do not require treatment) ____________________

6 (Not required for children under 6 years of age or applicantsfrom designated areas as described in Note 6)

D. Serological Test for Syphilis(Tests) . RPR VDRL ______________ . TPHA/TPPA _______________

. Other ___________ (Results) (Passed) (Failed)

15 (Not required for children under 15 years of age)

Male Female Name _________________ Sex

ID No. _________________ Passport No.

_________________

–––/

–––Date of Birth Nationality _________________

Age _________________ Phone No. _________________

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E. proof of positive measles and rubella antibody titers or measles and rubella vaccination certificatesa. Antibody test )

measles antibody titers Positive Negative Equivocalrubella antibody titers Positive Negative Equivocal

b. Vaccination Certificates (The Certificate should include the date of vaccination, the name of administering hospital or clinic and the batch no. of vaccine; the date of vaccination should be at least two weeks prior to going abroad)

Vaccination Certificates of Measles Vaccination Certificates of Rubella

c. (Having contraindications, not suitable for vaccination)

EXAMINATION FOR HANSEN’S DISEASESkin Examination

Normal Abnormal (not related to Hansen’s disease)

( )(Hansen’s disease suspect needs further exam). (Skin Biopsy)

. (Skin Smear) ( Finding bacilli in affected skin smears ) Negative

( Skin lesions combined with sensory loss or enlargement of peripheral nerves ) Yes No

(Results) (Passed) (Failed) (Not required for applicants from designated areas as described in Note 6)

(Note)This form is for

residence application.6 ( 1 1

) A child under 6 years old is not necessary to have laboratory examination, but the certificate of vaccination is necessary. Child age one and above should get at least one dose of measles and rubella vaccines.

12 Pregnant women and children under 12 years of age are exempted from chest X-ray examination. Pregnant women should undergo chest X-ray after the child’s birth.

15 HIV A child under 15 years old is not necessary to have Serological Test for HIV or Syphilis.

Applicants living in USA, Canada, Europe, New Zealand, Australia, Japan, South Korea, Hong Kong, Macao, Singapore or Israel are not required to undergo a stool examination for parasites or an examination for Hansen’s disease.

Hansen’s disease examination refers to careful examination of the entire body surface, which should be done with courtesy and respect to the applicant’s privacy. During the examination, the applicant is allowed to wear underwear and be accompanied by a friend or female medical personnel. Hospitals or clinics have the responsibilities to protect the privacy of the applicant and the examination should be done step by step. Hence, taking off all clothes at the same time should be avoided.

Result According to the above medical report of Mr./Mrs./Ms. , he/she has passed the examination has failed the examination needs further examination.

Name Signature(Chief Medical Technologist)

Name Signature( Chief Physician )

Name Signature( Superintendent )

Date / / Valid for Three Months

( )( )

( ) ( )

Entamoeba histolytica

Entamoeba hartmanniEntamoeba coli Endolimax nana Iodamoeba

butschlii Dientamoeba fragilis (Chilomastix mesnili)

RPR VDRL TPHA(TPPA)

RPR(+) VDRL(+) TPHA (TPPA)=1 320320

Appendix: Principles in determining the health status failed

Test Item Principles on the determination of failed items Serological Test for HIV Antibody

1. If the preliminary testing of the serological test for HIV antibody is positive for two consecutive times, confirmation testing by WB is required.

2. When findings of two consecutive WB testing (blood specimens collected at an interval of three months) are indeterminate, this item is considered qualified.

Chest X-ray 1. Active pulmonary tuberculosis (including tuberculous pleurisy) is unqualified. 2. Non-active pulmonary tuberculosis including calcified pulmonary tuberculosis, calcified foci and

enlargement of pleura, is considered qualified.Stool Examination for Parasites

1. By microscope examination, cases are determined unqualified if intestinal helminthes eggs or other protozoa such as Entamoeba histolytica, flagellates, ciliates and sporozoans are detected.

2. Blastocystis hominis and Amoeba protozoa such as Entamoeba hartmanni, Entaboeba coli, Endolimax nana, Iodamoeba butschlii, Dientamoeba fragilis, Chilomastix mesnili found through microscope examination are considered qualified and no treatment is required.

3. Pregnant women who have positive result for parasites examination are considered qualified and please have medical treatment after the child’s birth.

Serological Test for Syphilis

1. After testing by either RPR or VDRL together with TPHA(TPPA), if cases meet one of the following situations are considered failing the examination. (1)Active syphilis: must fit the criterion (1) + (2) or only the criterion (3). (2)Inactive syphilis: only fit the criterion (2).

2. Criterion:(1)Clinical symptoms with genital ulcers (chancres) or syphilis rash all over the body. (2)No past diagnosis of syphilis, a reactive nontreponemal test (i.e., VDRL or RPR), and

TPHA(TPPA) 1 320�(including 1 320) (3)A past history of syphilis therapy and a current nontreponemal test titer demonstrating fourfold or

greater increase from the last nontreponemal test titer. 3. Those that have failed the serological test for syphilis but have submitted a medical treatment

certificate are considered passing the examination.Measles,Rubella

The item is considered unqualified if measles or rubella antibody is negative (or equivocal) and no measles, rubella vaccination certificate issued after the antibody test is provided. Those who having contraindications, not suitable for vaccinations are considered qualified.

03/06/2012

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王大文

廣東惠州

王大文

02-23889393

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University Entrance Committee for Mainland Chinese Students ��

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