Application Form In Search of Roots Program

尋根申請表

(Please use Chinese characters, if knows, for Chinese name and village information)

English Name: __________________ Chinese Name: _____________________________

Address, City, State, Zip:_____________________________________________________

_________________________________________________________________________

Telephone number (includes are code) Home: ____________________________________

Mobile: ________________________________Work:_____________________________

Email Address: ____________________________________________________________

Name of School or Employer: ________________________________________________

Occupation or Course of Study: ______________________________________________

For students, grade/year in school: ____________________________________________

Father’s English Name: ____________________________________________________

Father's Chinese Name: ____________________________________________________

Father's Ancestral Village: __________________________________________________

Mother's English Name: ____________________________________________________

Mother's Chinese Name: ____________________________________________________

Mother's Ancestral Village: __________________________________________________

If applying as a family, please indicate number of persons to travel to China: ___________

Important: Please attach a brief statement/essay (no more than two pages) telling us why you would like to participate in the In Search of Roots Program.

I understand that acceptance into the In Search of Roots program will require me to attend regular seminar sessions and to do outside research.

DATE & SIGNATURE: _____________________________________________________