Ver2.2(2024.4.1)
Submit to Student Affairs Division
Submission Date: 12/4/2024

Example for Travel under University Program
To: the President of Shiga University of Medical Science

Please submit at least one month before you travel.

School Year

3Student ID******NameJohn Williams

OVERSEAS TRAVEL CHECK SHEET（For Students）
I hereby notify you that I will travel overseas for the following purpose(s) in accordance with the Article 9 of Shiga University of Medical
Science Regulation for Security Export Control, the Unfair Competition PreventionAct and the Convention on Biological Diversity.

IDestination, Duration, and Purpose of Travel
Transit and Destination
the United States of America(Country or Region)
Duration
From 12/6/2024 to 20/6/2024
Travel byUniversityProgram☒ Academic Conference (American ******* Society)☐ Study Abroad and Exchange☐ On-campus Program ()☐ Others()
To “II Travel by University Program”

PrivateOverseas
Travel☐ Leisure☐ Temporary Return to Home Country☐ Others (To “ III Itinerary and Destination”

Purpose of Travel)

II Travel by University Program
Supervisor

琵琶 花子

Source of Expenses

Travel Expenses : ☐ Own Expense ☒ Covered by University☐ Others ()Daily Allowances and Accommodation Fees :)☐ Own Expense ☒ Covered by University ☐ Others (Have you signed up for
the Insurance of "FutaiKaigaku"?

☒ Yes☐ No (Scheduled Contract Date : /)* You must purchase travel insurance before travel.

Ⅲ Itinerary and Destination
Duration
12/6/24FlightNumber
JL220
JL6

13/6/2024 to
18/6/2024
19/6/2024
JL5
20/6/2024
JL229
Emergency Contact while
Traveling
Emergency Contact
Japan during Travel

inItinerary: (separate attachment accepted)
PurposeName of Institution

Kansai International Airport toNew York City via Haneda
2024 American ******* Society
Congress
From New York City to KansaiInternational Airport via Haneda
Tel :090-****-****

To make an academic presentation
at the 2024 American ******* Society.

Please refer to the next page before you
fill out the “Itinerary and Destination”.

E-mail :*****@gmail.com

Name : Ann Williams(Relationship : Elder sister)
Address : **-* Sannomiyacho, Kobe Chuo-ku, Hyogo 650-0021 Japan
Tel : 090-***-****

Embassy of Your Country
Closest to the Destination

Embassy Name : British Consulate General New YorkE-mail :enquiry.net@newyork.mail.fco.gov.uk
Tel : +1 212 745 0200

Passport No.

********

Ver2.2(2024.4.1)☒ I confirmed MOFA's "Overseas Travel Safety Information".
To back side of “Ⅳ Check Items for the Personal Information Protection Act at Travel Overseas””

IV Check Items for the Personal Information ProtectionAct at Travel Overseas☒ I recognize that personal information is valuable and I pay close attention to the handling personal information
at most care.
☒ I do not acquire personal information by a deception or other wrongful means.

* Please be careful with the handling of personal information of EU resident (including E-mail address) based on
GDPR (General Data Protection Regulation).

V C Check items for Security Export Control, the Unfair Competition PreventionAct and the Convention on Biological Diversity
Will you travel with any
technologies that are not sold on）
the open market, intellectual ☒ No ☐ Yes（properties or devices including
If any answer is “Yes”, please contact the Management Office oflaptops and USB drives?
Will you transfer any biological Medical Research immediately.
resources or biological samples☒ No ☐ Yes（）
from overseas, or carry any withyou to overseas?

* If you transfer any biological resources or biological samples from overseas or carry any with you to overseas,
write the details in the brackets and please contact the Management Office of Medical Research immediately.
VI Pledge

I will comply with various laws, regulations and strive to comprehend information around the destination,and pledge to pay attention to safety. In addition, I will notify immediately if changes among other things
occur to the above-mentioned check items.
Signature

John Williams* Please understand that if the international affairs deteriorate or an incident or accident occur, we may share theabove information with related departments for safety confirmation.

Regarding the itinerary in “III Itinerary and Destination”
1.
2.
3.
4.

Management Office of Medical Research
You can also submit an itinerary prepared by travel
Director
ManagerStaff
agencies instead.
Please add lines, if you cannot fill in your entire itineraryon the form.
Please fill in your entire itinerary. You can submit it in anyformat.
Please be sure to write the flight numbers to/from Japan.
However, if you have not yet decided on your travel route
within the destination countries, you do not need to write
the flight numbers.

Please add lines, if you can't fill in the box.
Please be sure to check MOFA’s "Overseas Travel Safety Information"
before you travel.

Ver2.2(2024.4.1)
Submit to Student Affairs Division
Submission Date: 12/4/2024

Example for Private Overseas Travel
To: the President of Shiga University of Medical Science

Please submit at least one month before youtl

School Year

3Student ID******Name

Guo Xiaoping

OVERSEAS TRAVEL CHECK SHEET（For Students）
I hereby notify you that I will travel overseas for the following purpose(s) in accordance with the Article 9 of Shiga University of MedicalScience Regulation for Security Export Control, the Unfair Competition PreventionAct and the Convention on Biological Diversity.

I

Destination, Duration, and Purpose of Travel
Transit and Destination
People's Republic of China(Country or Region)
Duration
From 30/4/2024 to 3/5/2024
Travel byUniversity
ProgramPurpose of Travel
PrivateOverseas
Travel☐ Academic Conference ()☐ Study Abroad and Exchange☐ On-campus Program (☐ Others(
To “II Travel by University Program”))☐ Leisure☒ Temporary Return to Home Country☐ Others (To “ III Itinerary and Destination”)

II Travel by University Program
Supervisor

Source of ExpensesHave you signed up for
the Insurance of "FutaiKaigaku"?

Travel Expenses : ☐ Own Expense ☐ Covered by University☐ Others ()Daily Allowances and Accommodation Fees :)☐ Own Expense ☐ Covered by University ☐ Others (☐ Yes☐ No (Scheduled Contract Date : /)* You must purchase travel insurance before travel.

Ⅲ Itinerary and Destination
Duration
30/4/2024

FlightNumber
JL220

PurposeName of Institution

Undecided
2/5/2024

Undecided

3/5/2024

JL5

Emergency Contact while
Traveling
Emergency Contact
Japan during Travel

Itinerary: (separate attachment accepted)

inKansai International Airport toShanghai Pudong InternationalAirport
From Shanghai to Guanzhou by
train
From Guanzhou to Shanghai by
train
Pudong International Airport toKansai International Airport
Tel :090-****-****

Temporary return to home country.

Please refer to the next page before you
fill out the “Itinerary and Destination”.

E-mail :*****@gmail.com

Name : Guo Kexin(Relationship : Elder sister)
Address : **-* Sannomiyacho, Kobe Chuo-ku, Hyogo 650-0021 Japan
Tel : 090-***-****

Ver2.2(2024.4.1)

Embassy of Your Country
Closest to the DestinationEmbassy Name :Tel : +Passport No.

********E-mail :☒ I confirmed MOFA's "Overseas Travel Safety Information".
To back side of “Ⅳ Check Items for the Personal Information Protection Act at Travel Overseas””

IV Check Items for the Personal Information ProtectionAct at Travel Overseas☒ I recognize that personal information is valuable and I pay close attention to the handling personal information
at most care.
☒ I do not acquire personal information by a deception or other wrongful means.

* Please be careful with the handling of personal information of EU resident (including E-mail address) based on
GDPR (General Data Protection Regulation).

V Check items for Security Export Control, the Unfair Competition PreventionAct and the Convention on Biological Diversity
Will you travel with anytechnologies that are not sold on）
the open market, intellectual ☒ No ☐ Yes（properties or devices including
If any answer is “Yes”, please contact the Management Office oflaptops and USB drives?
Will you transfer any biological Medical Research immediately.
resources or biological samples☒ No ☐ Yes（）
from overseas, or carry any withyou to overseas?

* If you transfer any biological resources or biological samples from overseas or carry any with you to overseas,
write the details in the brackets and please contact the Management Office of Medical Research immediately.
VI Pledge
I will comply with various laws, regulations and strive to comprehend information around the destination,and pledge to pay attention to safety. In addition, I will notify immediately if changes among other things
occur to the above-mentioned check items.
Signature

Guo Xiaoping* Please understand that if the international affairs deteriorate or an incident or accident occur, we may share theabove information with related departments for safety confirmation.

Regarding the itinerary in “III Itinerary and Destination”
1.
2.
3.
4.

You can also submit an itinerary prepared by travel
Management Office of Medical Research
agencies instead.
Director
Manager
Staff
Please add lines, if you cannot fill in your entire itinerary onthe form.
Please fill in your entire itinerary. You can submit it in anyformat.
Please be sure to write the flight numbers to/from Japan.
However, if you have not yet decided on your travel route
within the destination countries, you do not need to write
the flight numbers.

Please add lines, if you can't fill in the box.
Please be sure to check MOFA’s "Overseas Travel Safety Information"
before you travel.