Receipt Number：

Application for 2023 SUMS Scholarship
Instructions

Photo

1. Type or write neatly by hand in block letters in Japanese or English.

(Write your name on

2. Use Arabic numerals (0.1.2.3…) and Western calendar.
3.

the back of a photo.)

Write proper nouns in full without abbreviation.

4.5cm × 3.5cm

To: The President of Shiga University of Medical Science,Name(in alphabet)

SurnameGiven nameMiddle name

* Write your name exactly as it appears on your passport
Date ofBirthAge(yyyy)

(mm)

(dd)

yrs

(as of April 1, 2024)

Gender□ Male□ Female* Applicants must have been born on or after April 2, 1988.
MaritalStatusNationality□

Single□MarriedCurrent
Address
EmailPhone

Name of
Institution
Final
Educational
RecordMajor
Faculty /Department
Year and Month of
Graduation/(yyyy)□ Check (if to be expected)(mm)

Name of
Institution

Current

Title /

Department

Position

Affiliation
Address

EmailPhone

1/(7)

1.

Receipt Number：Academic Record*If you took a leave of absence, specify the period and the reasons in the column “Remarks”.
School namePrimary
Education(ElementarySchool)

Location
Year & Monthof entrance &graduation

From/

to(yyyy / mm)/(yyyy / mm)

Period of schoolingattendedyrs

Period of schoolingattendedyrs

Period of schoolingattendedyrs

Period of schoolingattendedyrs

Period of schoolingattendedyrs

Period of schoolingattendedyrs

Remarks
School name
Lower Secondary
Education(MiddleSchool/JuniorHigh School)

Location
Year & Monthof entrance &graduation

From/

to(yyyy / mm)/(yyyy / mm)

Remarks
School name
Upper Secondary
Education((Senior) HighSchool)

Location
Year & Monthof entrance &graduation

From/to(yyyy / mm)/(yyyy / mm)

Remarks
School name
Tertiary (Higher)
Education(Undergraduate)

Location
Year & Monthof entrance &graduation

From/to(yyyy / mm)/(yyyy / mm)

Remarks
School name
Tertiary (Higher)
Education(Graduate)

Location
Year & Monthof entrance &graduation

From/

to(yyyy / mm)/(yyyy / mm)

Remarks
School name
Tertiary (Higher)
Education(Graduate)

Location
Year & Monthof entrance &graduation

From/to(yyyy / mm)/(yyyy / mm)

Remarks

yrs

Total years of schooling attended as of April 1, 2024
□Yes
（Issue date :（Country :Do you have a medical license?

2/(7)

□No））

Receipt Number：* If you have experiences of studying outside of your home country, fill in the following columns.
PeriodName of School / Institution

From□ PrivateTo//(yyyy / mm)(yyyy / mm)

From2.

□ Sponsored(Country:(by))□ PrivateTo//(yyyy / mm)(yyyy / mm)□ Sponsored(Country:)(by)Employment Record
Name and Address ofOrganization

Period ofEmployment
FromToFromToFromTo3.

Finance

Title / Position

Type of Work(yyyy / mm)//(yyyy / mm)//(yyyy / mm)//

ThesisHave you ever written a thesis?

□Yes□

No

State the titles or subjects of books and papers (including graduation thesis) authored by applicant, if
any, with the name, address of publisher and the date of publication.

3/(7)Receipt Number：

4.

Research Program

DesiredDepartment toEnroll inResearch
Subject

Please describe your study program within the 1000 words limit.

4/(7)Receipt Number：

5. Letter of Recommendation (from the authorized representative of the institution theapplicant belongs to)Name ofRecommender
Position ofRecommender

Recommendation

5/(7)

6.

Receipt Number：

Language ability
ReadingWriting

Speaking

ListeningJapaneseEnglishOthers()* Self-rate on a scale of 3 to 0.
Japanese language
qualifications

English language
qualifications

3 = Excellent

JLPT

1 = Fair

Total

Level

Score

0 = Poor

Other

Score

Other

Score

iBT
TOEFL

Other type(7.

2 = Good

IELTS)

Accompanying Dependents* Provide the following information if you plan to bring any family members to Japan.
* All expenses incurred by the presence of dependents must be borne by the grantee. Applicants are advised totake into consideration the various difficulties in finding accommodation and its expenses. Therefore, those whowant to accompany their families are well advised to come alone first and let them come after suitableaccommodation has been found.
Name

Relationship

Age

Nationality

８．Biwako Career Development Program for International Medical Students
Do you want to participate in “Biwako Career Development
Program for International Medical Students”?
*Please confirm the details of this program at the SUMS
Scholarship Guidelines for 2023.

6/(7)

□Yes

□No

Receipt Number：

I understand and accept all the conditions stated in the Application Guidelines for Shiga
University of Medical Science (SUMS) Scholarship for 2023 and upon confirmation of myqualifications for application as stated above, I hereby apply for this scholarship.
Applicant's

Date ofsignatureapplication

7/(7)年year/月month

日/day