Certificate Application Form
Application Date: Year 2019
Course from which you
Faculty/Graduate School from Department/Course from which graduated (for nonyou graduatedwhich you graduateddegree-seeking students)
Faculty of Humanities

Department of Social Sciences

Graduate School ofHumanities

Regional Culture major

Student ID number
when you enrolled（If unclear, please leaveblank.）

Month 2Date 20

Year and Month of Graduation

History CourseYear2005 Month3

History and Culture CourseYear2007 Month3YearMonth(Master's Course)

Graduate School of(Doctoral Course)

Course ofIf your name has changed, pleasewrite your current name in thecolumn below.

TARO YAMAGUCHIYour name at graduation※ If you need a certificate in English, please write your name exactly in Englsih as shown in your passport.

Date of BirthNationality
Your phone numberYear1982

Month6

Date

1

Japan

Remarks

Research Student(1st.April.2016 〜 30th.September.2016)

Phone number +81 (0)83-933-5000
E-mail： taroyama@yamaguchi-u.ac.jp※Please write if you were Research Student ,※ Please provide a phone number where you can be reached during the day on weekdays since we Special Auditing Student or Special Research
may contact you regarding the issuance of certificates.
Student.

Seal required
Types of Certificate
Certificates in JapaneseCertificates in English
Pnecessary
unnecessaryr
Graduate
Certificate■□copy
× 300yen ＝
0 yen
1 copy × 500yen ＝
500 yene Undergraduate
pTranscript□■
copy
× 300yen ＝
0 yen
1 copy × 500yen ＝
500 yena(Master's Course)■□copy
×300yen
＝
0yen
1copy
×500yen＝
500yenr
Graduate Certificate(Doctoral Course)e□□copy
× 300yen ＝
0 yen
copy× 500yen ＝
0 yen
d Graduate(Master's Course)■□copy× 300yen ＝
0 yen
1 copy × 500yen ＝
500 yenTranscript(Doctoral Course)□□Dcopy× 300yen ＝
0 yen
copy× 500yen ＝
0 yenoCertificate of Academic Ability
copy
× 300yen ＝
0 yenc（To obtain a teacher's license in Japan）
uTypes of license：□□me Othersi.e., First category teacher's license for junior high school, in Japanese;
Specialized teacher's license for high school, in geography and historyn（ Certificate of period oft□■copy
× 300yen ＝
0 yen
1 copy × 500yen ＝500yen
enrollment(Master)）s（）□□
copy× 300yen ＝0 yen
copy× 500yen ＝0yen
Total forJapanese

Intended use （ for job hunting
Placesubmitted （ Yamaguchi University0 yen

Total forEnglish2500yenTotal 2,500yen） e.g., for job hunting or to obtain some qualification）□All certificates（one copy each）must be sealed separately.

□All certificates（one copy each）must be sealed together.

Certificate
sealing ■Graduate certificates and transcripts (one copy each）must be sealed together.
method (if□Others（Please be specific.）
applicable)（）

Attachment
field for"Transfer
Payment Billand Receipt"

 Please paste proof of payment (Transfer Payment Bill and Receipt issued by Japan Post Bank) in the designatedcolumn for confirmation of payment.
 Certificates are dispatched in approximately five days (excluding Saturday, Sunday, and National holidays).
The time to issue a certificate in English or a Certificate of Academic Abilty isapproximately 10 days (excluding Saturday, Sunday, and National holidays).
 Certificates required for obtaining teaching licenses differ according to purpose, so please contact theauthorized department if you need a Certificate of Academic Ability.
Please contact the prefectual or municipal board of education of the place where your license was issued
regarding the Verification Letter for Issuance of a Teacher's License.

 Please feel free to contact the authorized departments mentioned on the web page should you have any queries or require special treatment.

Regarding handling of personal information
This application form is to be submitted for issuance of certificates; therefore, obtained information is not used for any purpose other than the issuance ofcertificates and is not provided to third parties, except in cases prescribed in Section 2 of Article 9 of the Act on the Protection of Personal Information Held by
Independent Administrative Agencies.

Check column before dispatch【Check column by the applicant】□Certificate Application Form
□Copy of Identification【Check column in case of application by proxy 】□Letter of Attorney□Reply envelope（Applicant's address and name are mentioned. Stamps are affixed.）□Proof of Payment□Copy of Identification of Delegate

ApplicationID：aa※Application ID will be fild by University