FOR OFFICIAL USE

Application No:

APPLICATION FOR ADMISSION[DOUBLE DEGREE PROGRAM]THE ENGLISH ENGINEERING EDUCATION PROGRAM (e3)
GRADUATE SCHOOL OF ENGINEERING
HOKKAIDO UNIVERSITY

Please paste a photo facingstraight at the camera
and taken within 3 months☐ MASTER’S PROGRAM☐ DOCTORAL PROGRAM☐ October 20

E

Desired enrolment:(1) Name (in Roman letters)
Surname/Family nameFirst name☐Female☐MarriedMiddle name(2-2) Do you possess Japanese nationality? ☐ Yes, I do.

M(2-1) Nationality☐Male☐Single

PLINSTRUCTIONS: Please type in the application. If handwriting, please write neatly in capital blockletters.
 Attach all the necessary documents specified in the list of application documents.
 Unclear or incomplete application without proper explanation will not be considered.

☐ No, I don’t.

(3) Date of Birth (DD/MM/YYYY)(4) Current Address
Zip code:

SAPhoneAddress:

E-mailAll the announcements will be sent by e-mail. Please make sure to provide a correct and valid e-mail address which
can be used for the whole period of your application.

(5) Permanent Address
Zip code:

Address:Phone

E-mail(6) Potential Supervisor

Please write down the names of one or two faculty members (professors/assoc. professors) and their laboratories
OR the names of two laboratories that you want to be considered for admission (in priority order)
Professor’s nameName of the Laboratory
Division
1st choice
Laboratory of
2nd choice

Laboratory of☐ I agree to be considered for acceptance by a different supervisor/laboratory.

(7) The Title of Research Proposal

Please write down the title of your planned research and attach a research proposal (in details if you are applying fora doctoral program). If the two professors or laboratories you have chosen deal with different research topics, pleasewrite down two research tittles, and attach two corresponding proposals.
(i)
(ii)

(8) Educational Background and currently enrolled program (expected to enroll program) at thepartner university which has a double degree agreement with the Graduate School of Engineering,
Hokkaido University.

Bachelor’s

DoctoralSA

OthersMMaster’s

Major Field

Period ofenrollment(month/year)

Type ofDiploma/Degree
awardedFinalGrade(GPA)

PLInstitution, Name of theUniversityEYou shall prepare official academic transcripts (complete for the graduate course(s) and the most recent by the timeof your application for your current program, if already available) and your graduation certificates. If your rank is notindicated therein, an official ranking certificate is necessary.
If you have spent a semester or more on exchange program in another university, have additional qualifications etc.
please specify it in the section “others”

From/

to/

From/

to/

From/

to/

From/

to/

Rank inClass ifany(rank/totalstudents)(9) Employment Record Please begin with the most recent employment.
Period ofemployment(month/year)

Organization, city, country

From/

to/

From/to/Position

Type of work, brief description(10) List of Publications and Graduation Thesis
If you have any publications please write down a full reference information including the name(s) of the author(s),title, publisher, date of publication, pages. When DOI is available, please include it. Attach abstracts and/orreprints.
Bachelor’s thesis title:Master’s thesis title:
List of publications (If the list is too long, please attach a separate sheet):12
3(11) English Proficiency

Please attach a score certificate or a medium of instruction certificate.

TOEFL, IELTS, TOEIC or other standardized English test score obtained within two years.
Test

Score

Date taken (DD/MM/YYYY)E☐ I have requested my TOEFL/IELTS score to be delivered directly to the e3 program’s office.

For applicants who completed full time degree in English and/or are native speakers:☐ I completed a full-time degree program which language of instruction was English.
☐ I am a native speaker of English.

The name of scholarship, grant, award,prize etc

PL(12) Have you been awarded any scholarship, grant, award or prize in the past?
If yes, please provide the details.
Awarding organization/
fundPeriod(month/year)

From/

to
From//to/Explain briefly about thescholarship, etc.

(13) Are you applying for other graduate schools and scholarships?

M

Please rest assured that this information doesn’t affect your chances to be selected.
☐ Yes (Please fill in the details below)

Scholarship/GrantSAUniversity

Country

Expected date of theresults announcement☐ No(14) How do you plan to support yourself during your study program?
☐ I’m applying for or was awarded a scholarship/educational loan:

Name of theorganization

scholarship(loan),

Status of the application (going toapply/nominated, etc)

Application
deadline

Expected date of theresults announcement(Please attach the scholarship information form and, if already nominated, a confirmation letter)☐I will primarily bare all the expenses by myself/ will be supported by a sponsor (even if not awarded a scholarship).
Please attach the international applicant’s declaration of Finance. If you wish to enroll even if your scholarship
application didn’t succeed please tick this option too. Self-funded applicants may qualify for such a support as Honors
Scholarship, tuition fee discount/waiver and study support for PhD students. Please check program’s page for details.

☐Other (specify)

(15) Referee

You shall request for the recommendation letter by yourself. If it’s not attached to your application please tick therelevant box. Please make sure that the recommendation letter sent by a referee directly to the program’s office canarrive before the deadline.
Name:
Position:☐ I have requested the referee to send the letter directly to the program’s office.

E-mail:(16) How did you know about our double degree program?

We would appreciate if you not only tick a box, but also provide some further details.

E☐1.Was advised by Study Abroad Office at home university ☐2.Was advised by the supervisor at home university☐3.e3 home page
☐4.Met professors/students from HU at international event etc.
☐5.During an internship/exchange program at HU ☐6.Was advised by peers/senior students☐7.Saw a brochure/announcement at home university ☐8.At a study abroad/ study in Japan fair etc.
☐9.Checked related to study abroad or Japan resources online ☐10.Other
Additional details:(17) Contact person in your home country

Address:

E-mail:SA

M

Tel/Fax:

Relationship with you:

PL

Name:

I understand that withholding pertinent information requested in this application form or giving false information will
make me ineligible for admission or liable for dismissal.
Signature

Date submitted

Postal address for submitting the application documents:

FOR OFFICIAL USEPartI

To be filled out by professor who accepts the applicant

E

English Engineering Education program (e3)International Affairs Office of Engineering (A1-05)
Graduate School of Engineering
Hokkaido University
Kita 13 Nishi 8, Kita-ku
Sapporo 060-8628, Japan
TEL:81-11-706-8089

Name:
Laboratory:
Signature:

PLI would like to accept this applicant as a master/doctoral student under my supervision. During the applicant’s
enrolment I will act as his/her contact person in Japan in case he/she is involved in some incidents and accidents.

Date:

Part II To be signed by Chairman of the Division the above professor belongs to after the applicant is
accepted by the professor above.

Name:
Division:

SA

Signature:M

I agree to allow this applicant to be considered for enrolment in the Division.

Date: