國立臺灣師範大學 學年度第 學期

學生課業輔導員學習獎勵方案終止申請表

National Taiwan Normal University Year _____ Semester _____

Application for termination of Student Tutor Award

課輔員資料Student Tutor Profile
課輔員 Student Tutor’s	姓名Name	學號Student ID
系所Department	班別Academic Level	□學士班Undergraduate ( 年級) □碩士班Master’s□博士班Doctoral
指導教師資料Advising Teacher Profile
教師姓名Name	服務單位Service unit	電話(O) Tel
受輔學生資料Tutored Student Profile
學生姓名Name	所屬系所Department	電話 Tel
終止方案原因Reason for termination□教師評估學生學習狀況不佳Poor tutoring performance as evaluated by Advising Teacher□學生自行評估無法負荷Unable to fulfill duty based on Tutor’s Self-Evaluation□其他Other
請簡述終止方案原因Please briefly describe the reason for termination.
申請學生簽章Signature of the Student Tutor	指導教師簽章Signature of the Advising Teacher
□已詳閱國立臺灣師範大學學生學習輔導實施要點，並了解終止方案後，即不得領取獎勵金。I have carefully read the “Directions for NTNU Student Tutoring Award” and understand that I would not receive the grant from the program after the termination.
系所主任簽章Signature of the Department Head

申請日期Date 年 月 日