KUMAMOTO GAKUEN UNIVERSITY
INTERNATIONAL EXCHANGE APPLICATION
1.Name: (write exactly same as it appears on your passport)
last (family or surname)first (given)

middle or maiden

Name in katakana:photograph of yourself.

last (family or surname)

2. Sex: male4. Date of Birth:

7. Marital Status:

first (given)

middle or maiden

 female

3. Nationality:

Write your name on the/5. Place of Birth:back of the photo.

/mo. day

6. Home town/city:

Please attach a recentyr.

town/citycity

state or country

state or country Married Single

8. Home Institution:
9. Highest degree completed or in progress at HOME institution:
Enrolled Faculty/College/School:
Enrolled Department:

Scholastic Year:1, 2, 3, 4

* circle the appropriate number.

Major field:
Minor field:
10. Date of graduation or expected graduation from your HOME institution:
11. Check the period of enrollment in KGU for which you are applying: one semester one year/

day/

yr.

starting (April, September), 20

mo.
12. Present Address: (valid untilmo.

day/yr.
/)Please write your address as it would appear on an envelope, using one line for each line of your address.

telephone (with area prefix)

E-mail address
13. Permanent Address: (mail will be sent here after the date given above)
telephone (with area prefix)

E-mail address1

14. The following information is necessary for immigration procedures:a) Information on your passport, if currently possessed:(1) Number:(2) Date of Expiration:b) Intended Date of Entry:/

mo. day//mo. day/yr.

c) Intended Port of Entry:yr.

d) Intended Length of Stay:e) Accompanying person, if any:  Yes  Nof) Place to Apply for Visa:g) Past Entry into/Stay in Japan:  Yes
If yes, the latest entry: frommo.

/time(s)/dayh) Criminal record (in Japan or overseas):yr.

/to Nomo.

/

day/

yr.

 Yes Details:/  Noi) Are any of your family members (Father, Mother, Spouse, Son, Daughter) currently resident
in Japan?  Yes

 No

If yes, please fill out the following columns.

Relationship

NameDate ofBirthResiding withNationality

applicant or not

Place ofemployment/
schoolStatus ofResidence

Yes / Noj) Educational Background
How many years of education have you had commencing with an Elementary School?
years
Please fill out the following columns to verify your above answer:(Begin with an elementary school and include your current home institution, college or university.)
Name of the school you attended

Entered (month / year)

2Left (month / year)////////////Name for Registration(Print or Type)

Instructions:KGU Student Identification Card does not have enough space to include full name if you
have the middle names. Therefore, as a rule, KGU Registrar’s Office asks you to choose twoparts of your name for the registration to KGU. You’re supposed to use the First and Last nameas they appear in your passport. But if your name is short enough and/or all the part of names
are considered as one name such as in Myanmar, we will include your middle name. In thatcase, please write down your request underneath.
KGU Student Identification Card could print your name only in Japanese, and for yourEnglish name, KATAKANA would be used. Thus, please write down your name inKATAKANA as well.
In the case you’re Chinese or Korean and have official kanji name, we could register andprint your name in kanji instead of KATAKANA. Therefore, please write down your name inkanji in addition to KATAKANA only if you have official ones.
Name for Registration:
In English:
LAST

FIRST

LAST

FIRST

LAST

FIRST

In KATAKANA:

In Kanji: If you would like to include your middle name, please write down your name in the way you
would like to register both in English and Japanese. Thank you.

3Study Plan at KGUYour Name:
Instructions:
Besides Mandatory Japanese Courses and Seminar in Japanese Culture, whichcourses would you like to take during the Spring Semester and/or the Fall Semester?
Please read the Notes in the next page, and refer to our university’s web site:
http://www.kumagaku.ac.jp/english/campus_life/courses
and write down the courses you’re interested in taking. This form will be used toaccept you to an appropriate department. It’s not a pre-registration form, thus, youcould change the courses to take after your arrival, if it’s necessary.
Fall Semester (Starting in September):Spring Semester (Starting in April):Any other courses you’d like to take in Japanese, if any:4

N o t e s
1.

Courses for Exchange Students
You will be assigned to a specific department, which will be determined by thecourses of your choice, but you are allowed to take any courses from any of our otherdepartments.
KGU offers the Japanese language courses designed especially for exchange
students who have limited skill in Japanese. In each semester, you must attend 4
Japanese classes a week if your level of Japanese language proficiency is not highenough to take Japanese classes of higher level and other regular courses taught inJapanese.
Besides the mandatory Japanese language courses and Seminar in Japanese
Culture, KGU offers the following courses taught in English or in English andJapanese bilingually, in the following departments:

International Communication Seminar I・II
Hospitality Seminar I･II・III

Department of Hospitality Management

Seminar III (Japanese Culture and Society)Department of Economics

Seminar I (World Englishes I)

Department of English

2.

Photos
The three photos you enclose besides the one you attach to the application form
would be used for your KGU Student ID Card, your Certificate of Eligibilityapplication, and the KGU International Student Card.

5Financial Questionnaire*The following information is necessary for your certificate of eligibility application and willbe also used for JASSO Scholarship recipient selection, so please make sure to fill in fully.
Name in print:

Last nameFirst nameMiddle name

1. Are you receiving any financial aid or loan at your home institution?  Yes  No
[monetary unit]
If “Yes”, please specify the total amount:()
Is it transferable from your home institution to KGU?

 Yes

If “Yes”, are there any requirements over your course registration at KGU?
 Yes
If “Yes”, what are they?

 No No

2. Who is going to finance your stay in Japan?
(1) Method of support and an amount of support per month (average) in Japanese yen Self (yen) Carrying from abroad ( Guarantor (in Japanyen)

 Remittance from outside Japan (yen)(Who Scholarship (yen)Whenyen)  Others ()yen)(2) If you have any Supporter other than yourself, please fill out the following:
NameRelationship

Address

Phone

Occupation (Name of employment)

PhoneAnnual incomeyen

3. In case that your answer in the question 2 (1) is scholarship, which of the following is yourscholarship agency? Please write down the name of your scholarship agency in parentheses.
 Japanese government
 Foreign government Public service corporation () Local self-governing body () Others ()6

Medical History
Health Insurance
Name of insured:

Insurance Co.

Policy number:Phone number:

Personal History
Height:Blood pressure:cm/

Weight:kg

Blood type (If known):

Have you ever had or do you now have any on the following: (please tick in box)
 anemia
 broken bones
 alcohol / drug abuse asthma sexually transmitted disease  rheumatic fever high blood pressure headaches
 eye problem
 emotional / mental disorder  convulsions / seizures
 back problem
 recent weight change tuberculosis
 stomach trouble
 arthritis
 hepatitis / liver problems
 female disorders
 scarlet fever diabetes
 cancer / tumors
 fainting / dizzy spells
 disability / permanent thyroid disease heart murmur / problems
 dental problems
 urinary problems
 hereditary disorder others (specify if any)
Comments on any of the above:
Have you had any major surgery?  Yes *specify

 NoAre you presently being treated for any medical condition?
 Yes *diagnosis

 No

Current medications:Allergy History
Medication:

 Yes *specify:

 No

Insects:

 Yes *specify:

 NoFood: Yes *specify:

 No

Inhalants:(i.e. pollen) Yes *specify:

 No

Next of kin or person to notify in case of emergency
Name:

Relation to applicant:Telephone number (with area prefix):
Mobile phone number:
FAX number (with area prefix):
E-mail address:7

Housing Questionnaire
Instructions:
We are asking the questions in order to help place you with a compatible roommate.
Therefore, please be accurate and specific. Please understand, however, that we may not beable to accommodate all of your requests due to various constraints.
氏名 Name: 男 Male  女 Female

質問 Questions

1. Do you smoke?

タバコを吸いますか Yes

 No

2. Are you allergic to smoke, or have any objection to living with someone who smokes?
あなたはタバコにアレルギーがありますか、または喫煙者と同室になることが嫌ですか？

 Yes, I’m allergic.

 Yes, I have objection.

 No

3. Do you consider yourself neat and organized? あなたは整理整頓が上手ですか？
 Yes, very much

 Yes, somewhat

 Not really Not at all

4. Do you consider yourself a day person or a night person? 昼型ですか、夜型ですか？
 Day person

 Night person

5. Please state two or three personal characteristics which describe yourself.
あなた自身について書いてください。

6. What type of persons do you think you can best get along with?
どんな人とうまくやっていけますか？

7. Are you vegetarian, or do you have any restrictions in food? 食物に制限がありますか？
 Yes

 No

If yes, please describe. それは何ですか？

健康状態 HealthState your general health: 一般的にIndicate any physical handicap you may have. 身体的なハンディキャップ
List health problems, serious allergies and/or current medication, if any.
健康上の問題、アレルギー等や現在治療中（投薬を受けている）病気など

8