APPLICATION FORM
for April 2018 Enrollment Double Degree Master’s Programbetween Graduate School of Science, Kyushu University and Faculty of Engineering, Universitas Gadjah Mada
(九州大学大学院理学府-ガジャマダ大学大学院工学研究科ダブルディグリープログラム 2018年4月入学者用申請書)
INSTRUCTIONS(記入上の注意)
1. The application should be typed if possible, or neatly handwritten in block letters.(明瞭に記入すること。) 2. Numbers should be in Arabic numerals.(数字は算用数字を用いること。)
3. Years should be written using the Anno Domini system.(年号はすべて西暦とすること。)
4. Proper nouns should be written in full and not abbreviated.(固有名詞はすべて正式な名称とし、一切省略しないこと。) *Personal data entered in this application will only be used for selection purposes.
(本申請書に記載された個人情報については、本選考のため以外には使用しない。)
1. Name in full, in Roman block capitals(Last, First, Middle)(姓名)
, , (family name) (first name) (middle name)
Name in Japanese Kanji or Katakana (Last, First)(漢字又はカタカナ氏名)
, , (family name) (first name) (middle name)
Sex : □ Male(男) □ Female(女)
2. Desired Specialized Field(志望専門分野)
3. Nationality(国籍)
4. Date of Birth(生年月日)
For a student of KU
(九大生用)
/ /
(Year) (Month) (Day) (Age (as of August 1st, 2018) (年齢2018年8月1日現在))
5. Present Address, Telephone Number, and E-mail Address(現住所、電話及びE-mail アドレス) Present Address(現住所)
Telephone(電話番号) E-mail Address(E-mail アドレス)
*Please write an e-mail address that you plan to use long term (prior to arriving in Japan and upon return home.)
(インドネシア渡航前~インドネシア留学中~帰国後にわたり使い続けることが予想されるE-mailアドレスを記入すること。)
6. Parent/ Guardian Contact Information(保護者連絡先)
Name(氏名):
Relationship to the Applicant(申請者との関係):
Address(現住所):
Telephone(電話番号):
E-mail Address(E-mail アドレス):
7. Educational Background(学歴)
Name and Address of School
(学校名及び所在地)
Year and Month of
Entrance and
Completion
(入学及び卒業年月)
Amount of time spent
at the school attended
(修学年数)
Diploma or Degree awarded,
Major subject
Elementary Education
(初等教育)
Elementary school
(小学校)
Name(学校名)
Location(所在地)
From(入学)
To (卒業)
years
(年)
and
months
(月)
Secondary Education
(中等教育)
Lower Secondary
School
(中学)
Name Location From To years and months Upper Secondary School
(高校)
Name Location From To years and months Higher Education
(高等教育)
Undergraduate Level
(大学)
Name Location From To years and months Graduate Level
(大学院)
Total years of schooling mentioned above
(以上を通算した全学校教育修学年数) years
*If the blank spaces above are not sufficient for the information required, please attach a separate sheet.
(*上欄に書ききれない場合には、適当な別紙に記入して添付すること。)
8. Publications
(List the Titles or Subjects of Books or Papers (including graduation thesis authored by the applicant), if any, with the name and address of the publisher and the date of publication.)
(著書、論文(卒業論文を含む。)があればその題名、出版社、出版年月日、出版場所を記すこと。) *Please attach abstracts of those papers to this application in separate sheets.
9. Foreign Language Proficiency(外国語能力)
(Evaluate your level and insert an × where appropriate in the following blank space.)
(外国語能力を自己評価のうえ、該当欄に×印を記入すること。)
Excellent (優)
Good (良)
Fair (可)
Poor (不可)
English (英語)
Japanese (日本語)
Other Language(その他) ( )
10. Family background(家族状況)
Name
(氏名) Relationship(続柄) (年齢)Age
Occupation
(職業) Address(住所)
*State your accompanying dependents to Japan. (注)留学する場合、同
伴予定の家族には該 当欄に×印を記入)
Father
Mother