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Management Info System

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APPLICATION FORM

JAPANESE GOVERNMENT(MONBUKAGAKUSHO:MEXT)SCHOLARSHIP FOR 2015

日本政府(文部科学省)奨学金留学生申請書

Undergraduate Students (学部留学生)

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.Year 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. (固有名詞を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 scholarship selection purposes, and contact information such as E-mail addresses will only be used for building networks after the student returns home and for sending information by the Japanese Government when necessary. (本申請書に記載された個人情報については、本奨学金の選考のために使用するほかは、特にE-mail アドレス等の連絡先については、帰国後における関係者のネットワークを作ること、及び必要に応じ日本政府より各種情報を送信する以外には使用しない。)

1.Name in full, in your native language (Sex) (姓名(自国語)) □Male(男) (Family name/Surname) (First name) (Middle name) □Female(女)

In Roman capital letters (Marital Status) (ローマ字) (Family name/Surname) (First name) (Middle name) □Single(未婚)
※Write your name exactly as it appears in your passport. (綴りはパスポートの表記と同一にすること) □Married(既婚)

2-1.Nationality(国籍) 2-2.Possession of Japanese nationality □Yes, I have (はい) (日本国籍を有する者) □No, I don’t have(いいえ)

3.Date of birth and Age as of April 1,2015(生年月日及び2015年4月1日現在の年齢)

19 Age Year(年) Month(月) Day(日) (年齢) ※as of April 1, 2015(2015年4月1日現在)

4.Home address and telephone number, facsimile number, E-mail address (現住所及び電話、ファックス番号又はE-mailアドレス)

Home address(現住所) Telephone/Facsimile number(電話番号/FAX番号) E-mail address ※If possible, write an E-mail address where you can be contacted for periods that include the time before you come to Japan, your stay in Japan and the period after you return home.(可能な限り、渡日前~日本留学中~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。)

5.Preferred field of study in Japan (日本での希望専攻分野) ※Select from the fields of study stipulated under “1.FIELDS OF STUDY” in Application Guidelines.(i.e. Mathematics, Physics ) (必ず募集要項「1.募集分野」から選んで記入すること。)

First choice (第1希望)

Second choice (第2希望)

Third choice (第3希望)

6.Field of study you specialized in at high school or university(過去在籍した高校又は大学での専攻分野)

7.Present status with name of school attending or employer:(現在の身分)
| Student :Name of school | |
| |in grade / will graduate |
| (在学中の者) (在籍学校名) |in |
| |(在学年次) (卒業見込年月) Year Month |
| Those in employment:Name of employer |
| (就労者) |
| (勤務先) |

8.Educational background: (学歴)
| |
| |Name and Address of School |Year and Month |Duration of |Diploma or Degree |
| | |of Entrance and |Attendances |awarded, Major Subject, |
| |(学校名及び所在地) |Completion |(修学年数) |Skipped years/levels |
| | |(入学及び卒業年月) | |(学位・資格・専攻科目・飛び級の状|
| | | | |況) |
|Elementary Education |Name |From | ye| |
|(初等教育) |(学校名) |(入学) |ars | |
|Elementary School | | | (年) | |
|(小学校) | | | | |
| |Location |To | and | |
| |(所在地) |(卒業) | mo| |
| | | |nths | |
| | | | (月) | |
|Secondary Education |Name |From | ye| |
|(中等教育) |(学校名) |(入学) |ars | |
|Lower Secondary School | | | (年) | |
|(中学) | | | | |
| |Location |To | and | |
| |(所在地) |(卒業) | mo| |
| | | |nths | |
| | | | (月) | |
|Upper Secondary School |Name |From | ye|*-1 |
|(高校) |(学校名) |(入学) |ars | |
| | | | (年) | |
| | | | | |
| |Location |To | and | |
| |(所在地) |(卒業) | mo| |
| | | |nths | |
| | | | (月) | |
|Higher Education |Name |From | ye| *-2 |
|(高等教育) |(学校名) |(入学) |ars | |
|Undergraduate Level | | | (年) | |
|(大学) | | | | |
| |Location |To | and | |
| |(所在地) |(卒業) | mo| |
| | | |nths | |
| | | | (月) | |
|Total of the years schooling mentioned above | ye|
|(以上を通算した全学校教育修学年数) |ars |
|As of April 1, 2015 | and |
|(2015年4月1日現在) | mo|
| |nths |

Notes: 1.Exclude kindergarten education or nursery school education. (幼稚園・保育所教育は含まれない。) 2.Preparatory education for university admission is included in upper secondary school. (いわゆる「大学予備教育」は中等教育に含まれる。) 3.If the applicant has passed the qualifying examination for admission to a university, indicate this in the blank with *-1.(「大学入学資格試験」に合格している場合には、その旨*-1欄に記入すること。 4.Any school years or levels skipped should be indicated in the fourth column(Diploma or Degree awarded, Major Subject, Skipped years and levels).(Example: Graduated high school in two years, skipping the 3rd year.) (いわゆる「飛び級」をしている場合には,その旨を該当する教育課程の「学位・資格,専門科目、飛び級の状況」欄に記載すること。 (例:高校3年次を飛び級により短期卒業)) 5.The applicant who has more than one major at his/her university should list all majors in the blank space with *-2(複数の分野を専攻することが認められている大学に在籍している学生は、その専攻分野を全て*-2欄に記入すること。)

9.Language proficiency: (語学力) (1) Evaluate your ability as “Excellent", “Good", or “Poor" in each blank space. (自己評価のうえ優、良、不可をもって記入すること。)
| |Reading |Writing |Speaking |
| |(読む能力) |(書く能力) |(話す能力) |
|Japanese | | | |
|(日本語) | | | |
|English | | | |
|(英語) | | | |
| Others( ) | | | |
|(その他) | | | |

10. Japanese language background, if any.(日本語の学習歴) ⅰ) Name and address of institution (学習機関名及びその住所)

ⅱ) Period of study (学習期間) from to Year(年) Month(月) Year(年) Month(月) Years(年間)

11.Reasons for choosing to major in the field of study entered in section 5. Specify reasons for each field of study entered in section 5. Also, ensure that the fields of study in this section are the same as the fields of study entered in section 5 (「5」の専攻分野を希望する理由 ※「5」で希望した専攻について、それぞれ具体的に記入すること。「5」と同一とすること。)

Field of study and reasons (専攻希望分野及び理由)

First choice(第1希望)

Second choice(第2希望)

Third choice(第3希望)

12.What kind of field are you planning to study in Japan? (日本に留学してどのような学問を学びたいか)

13. What kind of impression do you have of Japan? (日本にどのような印象を持っているか)

14.Description of desired occupation to be taken up after returning home. (帰国後に希望する職業)

15. Person to be notified in applicant's home country, in case of emergency: (緊急の際の母国の連絡先) ⅰ) Name in full: (氏名) ⅱ) Address with telephone number, facsimile number, E-mail address (住所;電話番号、ファックス番号又はE-mailアドレスを記入のこと。) Home Address(現住所) Telephone/Facsimile number(電話番号/FAX番号) E-mail address ⅲ) Occupation: (職業) ⅳ) Relationship with the applicant: (本人との関係)

ⅴ) name(s) of family member(s): (家族の氏名、職業、国籍)

Father(父) Occupation(職業) Nationality(国籍)

Mother(母) Occupation(職業) Nationality(国籍)

16.Immigration Records to Japan(日本への渡航記録)Begin with the most recent travel to Japan
| | |
|Date(日付) |Purpose(渡航目的) |
|From | |
| | |
|To | |
|From | |
| | |
|To | |

I understand and accept all the matters stated in the Application Guidelines for Japanese Government (MONBUKAGAKUSHO:MEXT) Scholarship for2015, and hereby apply for this scholarship.
(私は2015年度日本政府(文部科学省)奨学金留学生募集要項に記載されている事項をすべて了解して申請します。)
Date of application: (申請年月日)

Applicant's signature: (申請者署名)

Applicant's name (in Roman block letters capitals): (申請者氏名) -----------------------
-1-





| |
|Paste your photograph or |
|digital image taken within |
|the past 6 months. Write |
|your name and nationality in|
|block letters on the back of|
|the photo. |
| |
|(photo size:4.5 cm x 3.5 |
|cm) |
|(写真(4.5cm×3.5cm)) |

-1-

-2-

-3-

-4-

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