Form A (1/ 2)

International Environmental Security Leadership Program (IESLP)
Graduate School of Environmental Studies, Tohoku University
APPLICATION FOR ADMISSIONIESLP 2025
Please type or neatly print in English. Check the appropriate boxes. Do not staple documents.
Applicant’s registration number (for office use)

Master’s course

Doctoral course

Photograph
4cm×3cm

Name(1.6in×1.2in)in English

Digital photo
acceptable

In Chinese
Characters

Write yourLAST nameon the back side.

Family name / First name(if applicable)

Date ofYearMonthDay

birthNationalityAge (as of September 30, 2025)
GenderMaleFemale

Present status(with name and address of university or employer)

Present mailingaddress

Phone number

Fax number

E-mail address

Permanentaddress(if different from above)

Phone number

Fax number

Expected laboratory
Expected supervisor
Have you ever received the MEXT (Japanese Government) scholarship?

Yes

No

Yes

No

Yes

No

Do you intend to enter IESLP even if you are NOT awarded the MEXT scholarship?

Yes

No

Are you applying for, or going to receive, any other scholarships?

Yes

No

Yes

No

If Yes: [Program][Host institution][Term] From/to/(yyyy/mm)

Have you recently passed the First Screening for the MEXT scholarship (EmbassyRecommendation)?
For master's course candidate:
Do you intend to continue to study in the doctoral course of the IESLP?

If YES, provide some information of the scholarship. (Name, sponsor, duration, etc.)

Are you applying for any other graduate schools?
List institutions, programs, or positions you are currently applying for. (Optional)

安全保障輸出管理(for office use)

□ 承認済み（承認日：□ 手続不要□ その他月日）（確認事務担当者氏名：）

Form A (2/ 2)

APPLICATION FOR ADMISSIONIESLP 2025
Educational background
Name and address of School
Elementary
Education /Elementary School

Name

Secondary
Education / Lower
Secondary School

Name

Upper SecondarySchool

Name

Higher Education /Undergraduate
Level

Name

Year, month and date ofentrance and completion(yyyy / mm / dd)*required
From
To

Location

FromToLocation

FromToLocation

FromToLocation
Name

From

Graduate level

To

Location

Total years of schooling mentioned above

Amount of time spent at
the school attended

years andmonths

years andmonths

years andmonths

years andmonths

years andmonths

When taking leaveof absence, theperiod and reason

years

Research activities record
Name of institution

Position

From (yyyy / mm / dd) to

Number of years

FromToFromToFromToEmployment record
Name of office

Position

From (yyyy / mm / dd) to

Number of years

FromToFromToFromToFamily nameNameFirst nameMiddle name

DegreeType or nameAcquired date

Name of institution

For those who submit the certificate of expected graduation or provisional certificate: Do you guarantee to submit theYes

certificate of graduation/completion and diploma by September 30, 2025 in case you are accepted as an IESLP student?

No

Have you ever visited or stayed in Japan?
Date (yyyy/mm/dd)

Yes (list from your most recent visit)

No

Purpose of stay (e.g. sightseeing, visit my sister, exchange programs, etc.)

From
To
From
To

What is your primary (first) language?
I hereby certify that the information on this application form is true and complete.
I understand that the falsification in any of the information on the form may result in admission denial.

Signature:

Date (yyyy/mm/dd):