FORM 1

Application Form For 2013 Panasonic Scholarship 2013

Country

1)
() 2) 3) 4) 5)

Please fill out in English or Japanese. Translation into Japanese, if necessary Please type or print. Numbers should be in Arabic figures. Year should be written in the Anno Domini system. Proper nouns should be written in full.

[ Dateas of 2012
in Native Language

Sex Male

in Alphabet (English) exactly the same as written in your passport

Female
Marital Status Single

Full Name

Married
Family Name in Alphabet (English) First, Middle in Alphabet (English)

Date of Birth Nationality Religion Current Place of Study or Employment

19

Year

Month

Date

Photograph
Paste your photograph taken within the past 6-months, full face without hat. 4cm3cm

University Place of Employment

Major

Present Address and Telephone TEL

E-Mail

Name of Contact Person and Relations and Address in Home Country Name relations

Person to notify in Home Country

TEL Zip Code

FAX+

2013 Panasonic Scholarship

Level Elementary School Lower Secondary School Upper Secondary School College or University Name of School

FORM 2

Entrance and Completion Entrance Period Entrance Period Entrance Period Entrance Period Graduation Graduation Graduation Years Years Years Years

Location

Graduation

Location

Educational Background

Location

Location Place of Employment

Major Degree Period of Employment From To Period of Employment From To Occupation Type of Work

Place of Employment

Employment Record

Type of Work

Relationship Father Age

Address

Mother Age

M / F Brother/Sister Age M / F Brother/Sister Age Brother/Sister Age Spouse Age

Family Background

M / F

M / F

Children /Age

2013 Panasonic Scholarship

FORM

Japanese English Language Ability

1. Japanese: If you have had Japanese language training at Institution or University, state the followings.
(Period of Study) From(Month/Year)To(Month/Year) (Hours) Total Hours (Name of Institution or Course in university)

If you have taken Japanese Language Proficiency Test (JLPT), state the date and result.
(Date of the Test) (Place) (Your Score) Level: Score: Date Month Year Pass / Fail

If you have not taken JLPT, please evaluate your level and fill in the X mark in the followings.

JLPT N1 JLPT N2 JLPT N3 JLPT N4 JLPT N5

equivalent to equivalent to equivalent to equivalent to equivalent to No experience

N1 N2 N3 N4 N5 of

of JLPT of JLPT of JLPT of JLPT of JLPT learning Japanese Language

2. English: TOEFL TOEIC Please evaluate your level of English language. Please state your score, if you have taken Test of English as a Foreign Language (TOEFL) or Test of English for International Communication (TOEIC). Evaluate your level

Score

Very Good

Good

Fair

Poor

Date of the Test

Score

Date of the Test

FORM

2013 Panasonic Scholarship

Testimonial from the dean of the university you graduated from

To the Recommender: Please write in English or Japanese the reasons for recommendation why the applicant deserves Panasonic Scholarship recipient. Name of Applicant Graduate School/Course Name of Recommender

Reason for recommendation

Signature

Date

FORM 1

2013 Panasonic Scholarship

Study and Research Plan in Japan

Please state in detail the outline of your study and research plan (the objectives, progress, targets and schedule) in the graduate school in Japan. Fill in English or in Japanese.
[ Date2012 ]

Name of Applicant
Field of Study

Nationality

Details of Study Plan

Additional papers may be attached if necessary

FORM

2013 Panasonic Scholarship Study and Research Plan in Japan2

Name of Applicant Nationality

State the reason why you want to study in Japan?

Which university and field of study you wish to apply in Japan? In case you specify a target professor, state his/her name.

First Request

Second Request