Form11

Application for IJEP Short-Term Exchange Program

In Graduate School of Science and Technology (GSST),

Kumamoto University

Paste your passport

photograph taken within the

past- 6 months.

Graduate School of Science and Technology, Kumamoto University

Write your name and

2-39-1 Kurokami, Chuo-ku, Kumamoto 860-8555 JAPAN

nationality in block letters

on the back of the photo.

Tel: +81-96-342-3020

(43

E-mail: ask-gsst@gpo.kumamoto-u.ac.jp

1. Name (Please write it exactly as it appears in your passport):

In your native language
Last

In roman block capitals

Last

Middle

2. Nationality:

First

First

Male

Middle
Female

3. Date of birth:
/ / /
Month

Day

Year

Age

4. Present address (University):

Phone number:
Fax number:

E-mail address:

5. Present address (Home):

Phone number:
Fax number:

E-mail address:

6. Present Status, with the name of your university/institution

Name of University/Institution:
Faculty/ Department:
Year in Your School:
Masters Course First year Second year
Doctoral Course First year Second year Third year
7. Expected Graduation Date:

Application for IJEP Short-Term Exchange Program, GSST, Kumamoto University

Month

Year

Application for IJEP Short-Term Exchange Program, GSST, Kumamoto University

8. Academic history:
Name of Institution

Location

Period of

(city, country)

Numb

Attendance

er of

Month / Year

Years

Elementary Education / Name of elementary school

years

Secondary Education / Name of junior high school

years

Upper secondary / Name of high school

years

Higher Education / Name of University (Undergraduate)

years

Name of University (Master's Course)

years

Name of University (Doctorate Course)

years

Total Years of Education

years

9. Job experience:
Name of Workplace

Location

Period
Month / Year

1.
2.
3.
4.
5.

10. Language proficiency:

Evaluate your abilities by writing the word "excellent," "good," or "poor" where appropriate
in the following blanks.
Speaking
Listening
Reading
Writing
Japanese
English
Other

11. Scheduled duration of stay at Kumamoto University (your stay should be either for 6
months or one year):

6 months from March 2015 until August 2015

One year from March 2015 until February 2016
12. Prospective supervisor at GSST, if already decided:
Application for IJEP Short-Term Exchange Program, GSST, Kumamoto University

Name
Department
13. GPA calculated according to the method described in Qualification and
Conditions of Applicants in Application Information.
GPA=
14. Appointment of other scholarship
Indicate whether you will receive other scholarship while you receive JASSO scholarship.
Yes
Name of scholarship:
Total monthly amount:
No
15. Do you wish to stay at the International House (i.e. Kumamoto University
dormitory)?
Yes
No
16. Person(s) to contact in case of emergency:
Full Name:

Address:

Phone Number:

Fax Number:

E-mail Address:

Relationship to you:

Signature
I certify that all the information provided on this form and in the accompanying documents is
complete and accurate to the best of my knowledge.
Date:

Signature:

Application for IJEP Short-Term Exchange Program, GSST, Kumamoto University

State your current research at your university as well as your academic objectives and study plan at
Kumamoto University as detailed and concretely as possible. Statements must be typewritten in English.
Additional sheets of paper may be attached if necessary.

Current research at your university:

Academic objectives and study plan at Kumamoto University:

Application for IJEP Short-Term Exchange Program, GSST, Kumamoto University