University of Tsukuba

Graduate School of Systems and Information Engineering

Department of Policy and Planning Sciences

Application Form for Academic Advisor Assignmentfor International Research Students (Kenkyusei)
Notes
1: This form provides us with the information which helps us assign an appropriate academic advisor to you prior
to your official application for Research Student (Kenkyusei) in the Department of Policy and Planning Sciences.
2: This form is not related by any means with the International Student Center of the University of Tsukuba.
3: After your academic advisor has been determined, you must submit the official Application Form for ResearchStudent to the International Student Center of the University of Tsukuba.
4: The information provided in this form is kept confidential and it is used only by authorized administrative staff
for the purpose of finding academic advisors.
5: Inquiry about this form should be directed to ISSC (International Student Support Committee) of theDepartment of Policy and Planning Sciences at e-mail ryuugaku@sk.tsukuba.ac.jp, or phone +81-29-853-5178.
Instruction
1: Fill out the form in person in English (or in Japanese).
2: Use the Arabic numerals for all numbers. All dates should be in the form yy/mm/dd (unless otherwise specified)in Western calendar, for example, 83/02/23 for February 23rd, 1983, and 00/11/02 for November 2nd, 2000.
3: Do not use any abbreviation for proper nouns.
4: You may expand the frame size of each item as necessary in filling out the form.
5: Send the following materials by attachment to e-mail to ryuugaku@sk.tsukuba.ac.jp
1) The completed “Application Form for Academic Advisor Assignment”
2) Certificate of Graduation
3) Academic Transcript (undergraduate/graduate level)
You may also send the hardcopy of 1)-3) above to the following postal address:
ISSC (International Student Support Committee)
Department of Policy and Planning Sciences
Graduate School of Systems and Information Engineering
University of Tsukuba
1-1-1 Tennoudai, Tsukuba-shi, Ibaraki 305-8573 Japan
1. Date of This Application(yy/mm/dd)

2. Personal Data (mandatory)
Name in Full
In your mother language
Family Name:First Name:

Middle Nam:

In alphabet
Family Name:First Name:

Middle Name:

Nationality:

Mother Language:

Date of Birth (yy/mm/dd):
Sex :

Age:

□ Male □ Female

Current Address:
Phone:

Fax:

1/4

E- mail:
Current Status□ Student□ Employed□ Unemployed□ Other (Name of the University (if you are a student) or Employer:
Address of the University or Employer:
Phone:
E- mail:Fax:

3. Research Plan as Research Student (mandatory)
Period of Research Student: From (yy/mm):

To (yy/mm):

Title of Research Subject (within 20 words):
Detailed Research Plan (within 1,000 words; expand the space as necessary):

Financial Support Plan (scholarship, support by family, savings, etc.):

Names of Academic Advisors You Propose in Priority Order (up to three names)
1.
2.
3.
(See the list of faculty members for the current three programs related with Policy and Planning Sciences)2/4)

After/during the period of Research Student, do you intend to become a regular student by taking an entrance examination?

□ Yes→□ Master's Program in Department of Policy and Planning Sciences□ Doctoral Program in Department of Policy and Planning Sciences→ Other Program ()□ No

4. Educational Background
Education

Name and Address of School, Major Subject andName of Diploma or Degree Awarded

Dates of Entranceand Graduation

Required
Number ofYears

Name
Major
Undergraduate Level

From (yy/mm):

AddressYears
To (yy/mm):

Diploma
Name
Major
From (yy/mm):
Address
Graduate Levelyears
To (yy/mm):
DegreeTotal number of years for the above schooling

years

Leave of absence, if any

Years

ReasonFrom (yy/mm) :To (yy/mm):()

From (yy/mm) :To (yy/mm):()

5. Employment Record, beginning with the most recent one
Name and Address of Employer

Period of Employment
From:
To:

3/4

Position

Type of Work

6. Present or Past Field of Study

7. Academic/Professional Achievements (publications, presentations, patents, awards, and other related information)

8. Proficiency in the Japanese language
Name and address of the institution you studied Japanese:

Period of study or the total hours of study:

From:

To:
Hours

A certificate for Japanese proficiency:- A test of the Japanese language proficiency ( requested to attach a copy of the test score )- Others- None9. Proficiency in the English language- TOEIC( requested to attach a copy of the official score certificate )- TOEFL( requested to attach a copy of the official score report )- Others (STEP Eiken, United Nation’s Association’s Test of English, IELTS, CET-4, CET-6, etc.)
Remark: Your application for Research Student would not be under consideration if you could not provide us with yourproficiency in the English language.
10. Language Ability
Native Language
JapaneseEnglish
Other []□ Excellent □ Good □ Poor □ None
□ Excellent □ Good □ Poor □ None
□ Excellent □ Good □ Poor

11. Any Special Reason for Applying for Research Student4/4