Male SAMPLE - s-ge.t.kyoto-u.ac.jp
Transcript of Male SAMPLE - s-ge.t.kyoto-u.ac.jp
For University Use
Examinee’s Registration Number
Application Form for the 2017Undergraduate International Course Program of Civil Engineering
Note:
1. This form must be completed in English and in block letters.
2. Numbers should be in Arabic figures.
3. Proper nouns should be written in full, no abbreviations.
4. This form is also available on our website in PDF format.
(1) Name of
Applicant
(as of official ID)
(Family name)
(First name)
(Middle Name)
(2)Gender ☒ Male ☐ Female
(3)Marital Status ☐ Married ☒ Single
(4)Nationality American
(5)Date of Birth (Month) (Date) (Year)
01 31 1999
Place of Birth
(6)Current Academic
Status (Name and address
of current school, etc.)
3rd-year student, XXX high school,
12345, XXXXX Avenue, XXXXX, XXXXX U.S.A.
(7)Current Address
56789, XXXXX Avenue, XXXXX XXXXX, U.S.A.
(8)Phone Number (Home) country code +1-123-XXXXX-XXXXX
(Mobile) +1-123-XXXXX-XXXXX
FAX Number +1-124-XXXXX-XXXXX
E-mail Address [email protected]
* This E-mail address is essential for communications dealing with the admission process. If the Admissions Office
has trouble contacting you, you may be placed at a disadvantage.
Form A
1.
Form A-1
XXXXXXXXXXXXXXX
SAMPLE
For University Use
Examinee’s Registration Number
(9)Educational Background (Fill in your educational background precisely in chronological order.)
Type of School Name of School Country From
(Month) (Year)
To
(Month) (Year)
Primary XXX Elementary School U.S.A. 09 2004 08 2010
Secondary XXX Junior High School U.K. 09 2010 08 2013
Secondary XXX High School U.S.A. 09 2013 08 2014
Total years of Primary and Secondary Education: ( 12 ) years ( - ) months
Undergraduate
(If available)
Name of University or College From
(Month) (Year)
To
(Month) (Year)
(10)Employment Record
Name of Company (and location) From
(Month) (Year)
To
(Month) (Year)
(11)Language Background (Indicate languages known and in which language the applicant is most proficient in.)
Name of Language Level of Proficiency
English mother tongue
Spanish fluent
(12)Person to be notified in applicant’s home country in case of emergency
Name XXXXX, XXXXX XXXXXXX Relationship Father
Address
56789, XXXXX Avenue, XXXXX, XXXXX, U.S.A.
Phone Number (Home) country code +1-123-XXXXX-XXXXX
(Mobile) +1-123-XXXXX-XXXXX
FAX Number +1-124-XXXXX-XXXXX
E-mail Address [email protected]
Form A-2
↓If less than 12 years, you need to undergo Preliminary Verification.
SAMPLE
For University Use
Examinee’s Registration Number
(13)Family or relatives in Japan (if any)
Name Relationship
Address
(14)Source (s) of payment of tuition, and living expenses in Japan (the amount of money should be indicated).
☐ Scholarship Amount /per month
(kind of currency: )
Name of Scholarship
Name and Address of
Sponsoring
Organization
☑ Family Support Amount /per month
(kind of currency: )
Name Relationship
Address
☐ Others Amount /per month
(kind of currency: )
Name Relationship
Address
☒ I am applying for “Scholarship for Undergraduate International Course Program of Civil Engineering”. *Those who wish to apply for the scholarship must check the square at the time of submission of the application
documents.
*Those who do not have college student status of residence at the time of admission are not eligible to apply or this
scholarship.
*Please note that it is basically a merit-based scholarship to be renewed every year, depending on the recipient’s
academic performance. Successful applicants will be notified individually; the scholarship amount for the first year
will be announced to each successful applicant prior to admission.
Form A-3
500USD
XXXXX, XXXXX, XXXXXXX Father
56789, XXXXX Avenue, XXXXX, XXXXX U.S.A.
SAMPLE
Form A-4
For University Use
Examinee’s Registration Number
(15)Submission of Examination Score (Choose EJU or National Standard Test)
□ EJU ( *Please be sure to enclose a copy of the Examination Voucher for the EJU.)
Examination Site Examination Date
Examination Language □ English □ JapaneseExamination
Registration Number
□ National Standard Test: Name of Test ( )
Examination Date (MM/YYYY)
Examination Language
Examination Subjects □ Mathematics for the Science Courses □ Physics □ Chemistry
□ General Science including Physics & Chemistry
In case of GaoKao*,
Examination Site
(Name of city or province):
*GaoKao: Chinese National Higher Education Entrance Examination
(16)Submission of the Score of English Proficiency Test (Dates must be indicated as MM/DD/YYYY)
□ TOEFL ( TYPE of TOEFL: )
Examination Date Score
Official Score
Ordered
□ Online at registration□ Online/Telephone/Fax/Post Mail (order date )
□ IELTS (Academic Module)
Examination Date Score
Official Score Order date
(17)Desirable Venue for the Second Screening (Interview Examination)
*Please note that applicant maybe requested to take the second screening in the country near she/he resides at the time
of the interview depending on circumstances.
Name of City Country
Date: (MM/DD/YYYY)
Signature: (*Please sign your name by hand.)
2016
EJU Scores Math 2: Physics: Chemistry:
Honors Scholarship for EJU takers I have been selected as an awardee by JASSO for 2016 university admission.
I certify that all of the information I have provided on this application form and in any accompanying documents is true.
←Examination date must be later than August 1, 2014.
←Examination date must be later than August 1, 2014.
←Sign by hand!!
✔ SAT Subject01 2015
English
✔ ✔ ✔
✔ iBT
01 07 2015 100
✔
New York U.S.A.
08 22
* *
SAMPLE