特別聴講学生願書

作成日 Date:
Application Form for Special Auditor

Form 1

京都大学農学部長 殿
To: Dean of the Faculty of Agriculture, Kyoto University
申請者名（ローマ字）Applicant name in Roman letters:
在籍大学 Home University:
専攻分野 Field of Study at Home University:
入学年 Year of Enrollment:
京都大学在学中の所属大学での学年 Academic year in Home University while in Kyoto University:
卒業予定日 Expected Graduation Date at Home University (yyyy/mm):
住所 Mailing Address:
電話番号 Phone Number:
メール E-mail:
生年月日 Date of Birth:
性別 Gender:
国籍 Nationality:
日本国籍の有無 Japanese Nationality or Japanese Permanent Residency:
私は、以下のとおり京都大学農学部の特別聴講学生に出願します。
I hereby apply for the enrollment as a special auditor in the Faculty of Agriculture, Kyoto University.
滞在予定期間Planned period of stay
(Check your prospective period)□ Fall Semester (Oct.2020-Mar.2021)□ from Fall Semester to Spring Semester (Oct.2020-Sep.2021)□ Spring Semester (Apr.2021-Sep.2021)□ from Spring Semester to Fall Semester (Apr.2021-Mar.2022)
秋学期 Fall(second) semester (minimum 7 courses per semester)

履修予定科目(各学期 7 科目以上)
Prospective courses to take

春学期 Spring(first) semester (minimum 7 courses per semester)This is a pre-registration. You can finalize your registration after arriving in Japan.

Form 2
STATEMENT OF PURPOSE
In your statement, please explain the following as specifically and concretely as possible:(a) In what way your experience in Japan will be of significance to your education at the homeuniversity;(b) Why you chose to study at Kyoto University;(c) What you have learned in the past, if you have lived in foreign countries or had interculturalexperiences.
The statement should be typed, double-spaced and approximately 500 words in length. You
can attach any additional pages if necessary.
（留学目的：以下の項目についてできるだけ詳しく、ダブルスペース、５００語程度でタイプすること。
(a)日本での経験が大学教育の中でどのような意義を持つか(b)なぜ京都大学を選んだのか

外国での経験や異文化体験があれば、そこから何を学んだか）

Signature:Date:yyyy / mm / dd(c)過去にForm 3-1
作成日 Date:
京都大学農学部長 殿
To：Dean of the Faculty of Agriculture, Kyoto University

学生の受入依頼 Re: Official Request for Acceptance

下記の学生を、特別聴講学生として京都大学農学部に受け入れ願います。
受け入れにあたっては、学生交流協定に基づき、検定料、入学料及び授業料を不徴収として取り扱い願います。
We hereby request the acceptance of the below-stated student as a special auditor to the Faculty ofAgriculture, Kyoto University.
Based on Student Exchange Agreement between our university and Kyoto University, no application fee,
admission fee or tuition should be imposed to the student.

学生氏名 Name:
受入希望学科(*) Intended Department at the Faculty of Agriculture, Kyoto University(*):
上記(*)は京都大学農学部の決定により変更となる場合があります。
Note: A department to be enrolled in may be different from the above because that will be concluded by the Faculty of Agriculture, Kyoto University.

敬具
Sincerely yours,

署名
Signature
氏名 Name:
役職名 Job title:
所属大学 Name of Institution:

Form 3-2
推薦書 Recommendation Letter

被推薦学生氏名:
Recommended student’s name:
特別聴講学生の申請者として推薦するにふさわしいと思われる理由を記入ください。
State the reason why you recommend the applicant as special auditor

作成日 Date:
推薦者氏名 Name:
推薦者署名 Signature:
職名 Job title:
所属学部/学科 Department/Division:
所属大学 Name of Institution:

Form 4HEALTH CERTIFICATE
健康診断書
Name:

Date of Birth:(氏名)(生年月日)

yyyy / mm / dd

Please answer the questions below by checking the appropriate box, before submitting to aphysician for your physical examination. (健康診断を医師に申込む前に下記の設問に関しいずれかをチェックしてください。)

1. What diseases, disorders or injuries have you had in the past five years? (過去５年間にかかった病気あるいは怪我の名を書いてください。)

2. Do you have any allergies to foods, plants or animals?

Yes / No

(食物、動植物にアレルギーはありますか。)

3. Have you ever had an adverse reaction to medication?

Yes / No(薬に対してアレルギーはありますか。)

4. Are you taking medication now?

Yes / No

(現在、何か薬を飲んでいますか。)

To the physician (医師の方へ):
Please review the applicant’s medical history and complete the information below, giving
details concerning any positive indications. If there are any abnormalities in the following
systems, circle the appropriate answer and explain in detail. (患者の病・傷害歴をお読みになってから診断、ご記入ください。もし何か徴候がみられれば詳しくお書きください。下記の場所に異常がありますか。＋か－いずれかを○で囲んでください。)

1.
2.
3.
4.
5.

Head/Ears/Nose/Throat (頭/耳/鼻/喉) ＋／－
Respiratory (呼吸器)＋／－
Cardiovascular (心臓/血管)＋／－
Eyes (目)＋／－Genitourinary(泌尿生殖器)＋／－

6.Musculoskeletal (筋/骨)7.Metabolic/Endocrine (代謝/分泌)8.Neuropsychiatric (神経精神)9.Skin(皮膚)＋／－＋／－＋／－＋／－

Physician’s Comments (医師の所見):

After reviewing the applicant’s medical history and physical condition，I believe him/her to bein good physical and mental health, free of any chronic conditions, disorders or contagious
diseases, and capable physically and mentally of completing a one to two semester term ofstudy in Kyoto University. (患者の病歴と健康状態を診た結果、私は上記の者が、肉体的にも精神的にも健康で、持病、伝染病、身体の不調無く、京都大学で 1, 2 学期間勉強を続けるのに支障はないと確信します。)

Physician’s signature (医師の署名)

Date(日付):
yyyy / mm / dd

Physician’s name<please print>(医師の名前):
Address (住所):tel/fax/e-mail:Photo Requirement

You need to submit 2 photos as specified below. Please write your full name on theback of photo.

1. A photo that shows the applicant him/herself alone.
2. A photo of the dimensions specified in the drawing above, excluding the photo's outerborder (the dimension of the face refers to the portion from the top of the head [includingthe hair] to the lower end of the chin).
3. The person should face squarely to the front and remove hats, caps or head coverings.
4. No background or shadows.
5. Must be clear.
6. Must be taken within one month prior to submission.
7. Must be different from the one on your passport.