Application for certificate issuanceTo the President of Hitotsubashi University
Application date(yyyy/mm/dd):

Furigana (phonetic[Enter only when different name isdesired]characters)

Japanese
1

Nameused whilein school

NameRomancharacters[to be written only by applicant for English certificate]□ Request certificate inname used while in school□ Request certificate in new
surname *Note (1)（yyyy/mm/dd）

2

Date of birth

3

Faculty you
graduated□Commerce and Management □Economics□Law□Social Sciences

4

Student ID
Number[Enter only when you remember it]

5

Date of enrollment(yyyy / mm)

6Year/month ofgraduation(yyyy / mm)

7

Current address

8Telephone

9

Email address

10

Purpose of use□Undergraduate□Auditing student□Exchange student□Transferred from anotherfacultyenrolled□Admitted as graduate fromanother university□Graduated□Withdrawn□Dropped from rolls

Postal code/address[Enter the number which can be reached in daytime on weekdays]--@□Employment□Qualification exam
□Application for visa, etc. (country name:□Others (□Study abroad))[Enter destinations of all certificates requested] [Enter the name of the test for qualification exams]

Destination ofsubmission□I agree to allow the University to respond without contacting me in caseof fact-checking and other inquiries from the destination of the submission
regarding issuance of this certificate.
Japanese

11

Types ofcertificates
English12□Academictranscript□Certificate ofgraduation□Certificate ofwithdrawal□Academictranscript□Certificate ofgraduation□Certificate ofwithdrawal□Certificate
showing notcounted in GPA(No. of copies)(No. of copies)[Signature or seal]□Others (identify
specific document)(No. of copies)(No. of copies)(No. of copies)(No. of copies)(No. of copies)□Others (identifyspecific document)(No. of copies)(No. of copies)【Continue to the next page】

□Not necessary
13

Seal off*Note (2)14

Receipt ofcertificates

15

Remarks□Necessary□Each certificate in one envelope□( ) sets of academic transcript & certificate of graduation□Others (identify specific document)□Visit Educational Affairs Division in person□Application by proxy [letter of proxy, etc.

□By postal mailrequired] *Note (3)□Desire direct delivery abroad● This application form is for faculty use only. Those who request graduate school certificates are advised to use an application form of each school.
● Certificate issuance is free of charge.
*Note (1) An applicant who requests certificate issuance in his/her new surname is required to submit a [notification of change in name, etc.] and an [extract ofhis/her family register] issued within the past 3 months, both for the first application only.
*Note (2) “Seal off” means tightly sealing this University’s official envelope--containing a certificate--with an official seal affixed.
In case you need a tightly sealed envelope, please enclose a self-addressed stamped return-mail envelope a little larger than a standard-size envelope sothat it can enclose a sealed-off envelope of rectangular size type 3.
*Note (3) In case you entrust the procedure of certificate issuance to a third party, please submit a [letter of proxy], a [copy of the proxy mandator’s ID] and a [copy ofthe proxy’s ID] as well as an [application for certificate issuance]. IDs include a driver’s license, a passport, a health insurance card, and a student ID issued
by Hitotsubashi University.