ϫ㸬ᡤᐃࡢᵝᘧ㸬ධᏛ㢪᭩㸦ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝㸧≉ᐃ㢮ᆺヱᙜᛶࡢ⮬ᕫ⏦࿌᭩㸬Ꮫᰯᩍ⫱➼ᒚṔ᭩㸬ᚿᮃ⌮⏤᭩ͤᡤᐃࡢᵝᘧࡣᮏᏛ࣮࣒࣮࣍࣌ࢪ㸦ࢺࢵࣉ࣮࣌ࢪЍධᏛ᱌ෆЍᡤᐃࡢᵝᘧ㸧࠿ࡽࢲ࣮࢘ࣥࣟࢻࡋࠊධຊࡋ࡚ࡃࡔࡉ࠸ࠋ㸦ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝ / Recommendation for Overseas Residents

ͤ

ཷ㦂␒ྕ

࣭⼥ྜ⛉Ꮫඹྠᑓᨷ / Division of Transdisciplinary Sciences㸧

Examinee’s Number໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉⼥ྜ⛉Ꮫඹྠᑓᨷ༤ኈᚋᮇㄢ⛬ධᏛ㢪᭩ͤḍࡣグධࡋ࡞࠸ࡇ࡜ / Official use onlyApplication Form - Doctoral Program / Japan Advanced Institute of Science and Technology‫ࡣ࡟ڧ‬ཷ㦂ࡍࡿ㑅ᢤヨ㦂ྡ/࡛ࢳ࢙ࢵࢡࡍࡿࡇ࡜ࠋ/ Please check the appropriate box.

ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ/Examination for Admission on Recommendation for Overseas Residents

Type of Examination௧࿴㸵ᖺ㸲᭶ / April 2025ධᏛᕼᮃᖺ᭶/ Admission Term෗┿ / Photograph

ࣇࣜ࢞ࢼ
ࡓ࡚

ᛶู / GenderẶྡ / Nameࡼࡇ

㸲cm×㸱cm /እᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධ‫ ⏨܆‬/ Male/ International students must write

4 cm long × 3 cm wide䖴ዪ / Female

their names in English.

    ᖺ / Year    ᭶ / Month    ᪥ / Day⏕ᖺ᭶᪥ / Date of Birthᕼᮃ୺௵◊✲ᣦᑟᩍဨྡ / Intended Supervisor*ເ㞟せ㡯ࡢࠕฟ㢪㈨᱁ࠖ࠿ࡽ 1 ࡘ㑅ᢥ /See Eligibility Requirements on the Application Guide.

‫܆‬㸯‫܆‬㸰‫܆‬㸱‫܆‬㸲‫܆‬㸳‫܆‬㸴‫܆‬㸵‫܆‬㸶ฟ㢪㈨᱁ࢆ‶ࡓࡍ᭱⤊ᏛṔ /኱Ꮫ㝔ྡ/University Eligibility Requirement◊✲⛉ྡ/Department

տಟ஢ / Graduatedտಟ஢ぢ㎸ / Will graduate⌧ఫᡤ / Current Address

ᑓᨷྡ/Majorin     ᖺ / Year    ᭶ / Monthࠛᦠᖏ㟁ヰ/ Cell PhoneEmail⮬Ꮿ㟁ヰ/ Home Phone⥭ᛴ᫬ࡢ㐃⤡ඛఫᡤ / Emergency contact address  ࠛẶྡ / Name⥆᯶ / Relationship㟁ヰ / PhoneᏛ     Ṕ / Educational Background㧗➼Ꮫᰯ࠿ࡽグධࠋ኱Ꮫ࡟࠾࠸࡚ࡣᏛ㒊࣭Ꮫ⛉ࠊ኱Ꮫ㝔࡟࠾࠸࡚ࡣ◊✲⛉࣭ᑓᨷࡲ࡛グධࠋ኱Ꮫ➼࡛◊✲⏕࡜ࡋ࡚ᅾᏛṔࡀ࠶ࡿሙྜࡣᏛṔḍ࡟ࡑࡢᮇ㛫ࡶグධࠋ
Applicants must fill in their educational background starting from high school until the most recent school.
If applicable, please also write any experience as a research student at a university or other institution. Please fill in the department and faculty of the university.

ධᏛ࣭༞ᴗ㸦ぢ㎸㸧ᖺ᭶ / Period of (Expected) Attendance  Ꮫᰯ➼ࡢྡ⛠ / Name of School㧗➼Ꮫᰯ/ Secondary School

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month㸦ᡤᅾᅜ/Country     㸧⫋     Ṕ / Professional Backgroundධ♫࣭㏥⫋ᖺ᭶ / Period of Employment௻ᴗ࣭ᶵ㛵➼ྡ⛠/ Name of Organization  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month⌧᭷⫋⪅㑅ᢥḍ / Will you quit your job at the time of enrollment?
༊ศ/ᅜ⡠/ NationalityẶྡ / Name

CategoryFamilyධᏛᚋ࡟㹙‫܆‬㏥⫋ࡍࡿ࣭‫܆‬㏥⫋ࡋ࡞࠸㹛ணᐃ࡛ࡍࠋ/( ‫܆‬Yes࣭‫܆‬No )‫␃㈝⚾܆‬Ꮫ⏕ / Privately financed international students‫܆‬᪥ᮏᨻᗓዡᏛ㔠␃Ꮫ⏕ / Japanese government (MEXT) scholarship students‫܆‬እᅜᨻᗓὴ㐵␃Ꮫ⏕ / Foreign government scholarship students
Given

Other (s)ゝㄒ⬟ຊ㸦⮬ᕫホ౯ࢆ excellent࣭good࣭fair࣭poor ࠿ࡽ㑅ᢥ㸧/ Language Proficiency (Evaluate the level as excellent, good, fair or poor.)ⱥㄒ/ㄞࡴ/ Reading

᭩ࡃ/ Writing⪺ࡃ/ Listeningヰࡍ/ Speaking

English᪥ᮏㄒ/‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor

ㄞࡴ/ Reading

᭩ࡃ/ Writing⪺ࡃ/ Listeningヰࡍ/ Speaking

Japanese‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poorᕼᮃࡍࡿ࢖ࣀ࣮࣋ࢩࣙࣥ㸦㸱ࡘࡢࢳࣕࣞࣥࢪ㸧 /Desired Challenge㑅ᢥࡋࡓ࢖ࣀ࣮࣋ࢩࣙࣥࡣࠊ࠶ࡃࡲ࡛ࡶධヨࡢཧ⪃࡟ࡍࡿࡶࡢ࡛࠶ࡾࠊධᏛᚋࡢ࢖ࣀ࣮࣋ࢩࣙࣥࡢ㑅ᢥ࡟ࡣ୍ษᙳ㡪ࡋ࡞࠸ࠋ/ This information will be used only for the examination andwill not affect the actual desired Challenge.
*ࠕ㸱ࡘࡢᣮᡓⓗ࡞࢖ࣀ࣮࣋ࢩࣙࣥࡢᯟ⤌ࡳ㸦㸱ࡘࡢࢳࣕࣞࣥࢪ㸧ࠖࡢ࠺ࡕࠊᕼᮃࡍࡿ㸯ࡘࢆ㑅ᢥ / Select one type of “Innovation” in which you want to challenge out of three: LifeInnovation, Green Innovation, System Innovation.

‫ ࣥࣙࢩ࣮࣋ࣀ࢖ࣇ࢖ࣛ܆‬/Life Innovation‫ ࣥࣙࢩ࣮࣋ࣀ࢖࣮ࣥࣜࢢ܆‬/Green Innovation‫ ࣥࣙࢩ࣮࣋ࣀ࢖࣒ࢸࢫࢩ܆‬/

System Innovation≉ᐃ㢮ᆺヱᙜᛶ䛾⮬ᕫ⏦࿌᭩㻛 Self-Declaration Form of Applicability to a Specific Category
እᅜⅭ᭰ཬࡧእᅜ㈠᫆ἲ㸦௨ୗࠕእⅭἲࠖ࡜࠸࠺ࠋ㸧࡟ᇶ࡙ࡁࠊつไᑐ㇟࡜࡞ࡿ㈌≀ࡢ㍺ฟࡸᢏ⾡ࡢᥦ౪࡟ࡘ࠸࡚⤒῭⏘ᴗ኱⮧ࡢチྍࢆཷࡅࡿ⩏ົࡀㄢࡏࡽࢀ࡚࠸ࡿࡇ࡜࠿ࡽࠊᮏᏛ࡛ࡣࠕᅜ❧኱Ꮫἲே໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱ᏛᏳ඲ಖ
㞀㍺ฟ⟶⌮つ๎ࠖࢆᐃࡵࠊᏳ඲ಖ㞀㍺ฟ⟶⌮࡟ྲྀࡾ⤌ࢇ࡛࠾ࡾࡲࡍࠋᏳ඲ಖ㞀㍺ฟ⟶⌮࡛ࡣࠊ㠀ᒃఫ⪅㸦᪥ᮏධᅜᚋ㸴᭶ᮍ‶ࡢᏛ⏕➼㸧࡬ࡢᢏ⾡➼ࡢᥦ౪࡟ຍ࠼ࠊᒃఫ⪅㸦᪥ᮏධᅜᚋ㸴᭶௨ୖ⤒㐣ࡋࡓᏛ⏕➼㸧࡛࠶ࡗ࡚ࡶ㠀ᒃఫ⪅ࡢ㠀ᖖ࡟ᙉ࠸ᙳ㡪ୗ࡟࠶ࡿሙྜࠊࡑࡢࡼ࠺࡞ᒃఫ⪅㸦≉ᐃ㢮ᆺヱᙜ⪅㸧࡟ᑐࡍࡿᢏ⾡➼ࡢᥦ౪࡟ࡘ࠸࡚ࡶࠕࡳ࡞ࡋ㍺ฟࠖ࡜ࡋ࡚⟶⌮ࡢᑐ㇟࡜࡞ࡾࡲࡍࠋࡇࡢࡇ࡜࠿ࡽࠊᮏᏛ࡬ࡢฟ㢪ࢆᕼᮃࡍࡿ᪉࡟ࡣእⅭἲ࡟ᇶ࡙ࡃࠕࡳ࡞ࡋ㍺ฟࠖ࡟࠾ࡅࡿ⟶⌮ᑐ㇟࡛࠶ࡿ࠿࡝࠺࠿ࡢ⮬ᕫ⏦࿌ࢆ࠾㢪࠸ࡋ࡚࠾ࡾࡲࡍࠋࡈ⮬㌟ࡢ≧ἣ࡟ࡘ࠸࡚ࠊู⣬ࡢࣇ࣮ࣟࢳ࣮ࣕࢺࢆཧ↷࠸ࡓࡔࡁࠊኴᯟෆࢆグධࡢୖࠊฟ㢪᭩㢮࡜ేࡏ࡚ࡈᥦฟࡃࡔࡉ࠸ࠋ
Since any export of goods or transfer of technologies subject to the controls requires a license from the Minister ofMETI (the Ministry of Economy, Trade and Industry) based on the Foreign Exchange and Foreign Trade Act (hereafterreferred to as “FEFTA”), JAIST has established regulations for Security Export Control and we are working on it.
 Transferring technologies, etc. to a none-resident (a student who has been staying in Japan for 6 months or less, etc.)
and to a resident ( a student who has been staying in Japan for 6 months or more, etc.) who is under the significant
influence of a non-resident, (a person who falls under the specific category), are subject to control as “deemed exportcontrol”.
 We ask all applicants for admission to self-declare whether or not they are subject to the "deemed export control"
based on the FEFTA. Please refer to the attached flowchart, fill in the form and submit it along with your application
documents.

㸦ὀ㸯 / Note 1㸧እᅜே␃Ꮫ⏕ࡣẶྡࢆⱥᏐ࡛グධࡍࡿࡇ࡜ࠋ / International students must write their names in English.

グධᖺ᭶᪥ / Date       ᖺ / Year     ᭶ / Month     ᪥ / DayẶྡ /Name㸦ὀ㸯 / See Note 1㸧ㄢ⛬Program‫܆‬༤ኈ๓ᮇㄢ⛬Master’s Program(Place a check mark in the appropriate box.㸧 ‫܆‬༤ኈᚋᮇㄢ⛬Doctoral Program≉ ᐃ 㢮 ᆺ ヱ ᙜ ᛶ ࡢ ⮬ ᕫ ⏦ ࿌ / Self-‫܆‬㢮ᆺձ࡟ヱᙜ / I fall under the category 1

Declaration of Applicability to a SpecificCategory‫܆‬㢮ᆺղ࡟ヱᙜ / I fall under the category 2‫܆‬㢮ᆺձղࡢ୧᪉࡟ヱᙜ / I fall under the category 1 and 2(Place a check mark in the appropriate box.㸧‫ࡶ࡟ࢀࡎ࠸܆‬ヱᙜࡋ࡞࠸ / I do not fall under any of the categories㸦ู⣬$SSHQGL[㸧㸦⼥ྜ⛉Ꮫඹྠᑓᨷ / Division of Transdisciplinary Sciences㸧ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ
 Official use onlyͤཷ㦂␒ྕᏛᰯᩍ⫱➼ᒚṔ᭩
Curriculum VitaeධᏛᕼᮃᖺ᭶

Examinee’s Number௧࿴㸵ᖺ㸲᭶

Semester for which
you are applying

April 2025༤ኈᚋᮇㄢ⛬
Doctoral Programᚿᮃㄢ⛬
Intended program⏕ᖺ᭶᪥
Date of BirthYearMonthDayẶྡ
Full name inEnglish

FamilyGivenOther(s)㹙Ꮫ Ṕ Educational Background㹛ᏛᰯྡཬࡧᡤᅾᆅName and location of schoolṇつࡢಟᏛᖺᩘධᏛཬࡧ༞ᴗᖺ᭶ಟᏛᖺᩘ

Officially requiredYear and month of enrollment andDuration of

number of years

graduation or completionattendanceof schoolingึ➼ᩍ⫱Primary EducationᏛᰯྡධᏛ   㸭

Name

FromYearᏛ఩࣭㈨᱁
Qualification(degree, diploma
or certificate)ᖺMonthyears
andᑠᏛᰯ

ᡤᅾᆅ

Primary School

Location

୰➼ᩍ⫱

୰Ꮫ

Secondary
Education

Lower㧗ᰯ

SecondarySchool

Upper㧗➼ᩍ⫱ධᏛ   㸭

FromYearMonth᭶   months

Monthyears

ᖺandᖺ ༞ᴗᡤᅾᆅyears   㸭ToYearᏛᰯྡධᏛ   㸭

NameFromYearᖺ ༞ᴗᡤᅾᆅ

years

YearධᏛ   㸭Name

FromYear

Undergraduate Level

Location

yearsYearධᏛ   㸭

Name

FromYearyears

LocationyearsᖺMonth᭶   months

Monthyears

ᖺandToᖺ ༞ᴗMonth   㸭Ꮫᰯྡᡤᅾᆅ᭶   months

andToᖺ ༞ᴗMonth   㸭Ꮫᰯྡ
ᡤᅾᆅGraduate Level

YearName኱Ꮫ኱Ꮫ㝔ToᏛᰯྡLocation

Higher Education   㸭years

Location୰Ꮫཬࡧ㧗ᰯᖺ ༞ᴗMonth᭶   months

Monthyears

ᖺand   㸭ToYearMonth᭶   months

ᖺyears௨ୖࢆ㏻⟬ࡋࡓ඲Ꮫᰯᩍ⫱ಟᏛᖺᩘ

andTotal years of the schooling mentioned above᭶   monthsᖺyearsὀ㸧ୖḍ࡟᭩ࡁࡁࢀ࡞࠸ሙྜ࡟ࡣࠊ㐺ᐅู⣬࡟グධࡋ࡚ῧ௜ࡍࡿࡇ࡜ࠋIf the given space is not enough, attach additional sheets.

㹙⫋ Ṕ Professional Background㹛໅ົඛཬࡧᡤᅾᆅName and location of organization໅ົᮇ㛫Period of employment

FromToFromToFromToFromToὀ㸧⹫ഇࡢ஦㡯ࢆグ㍕ࡋࠊཪࡣᙜ↛グ㍕ࡍ࡭ࡁ஦㡯ࢆグධࡋ࡞࠿ࡗࡓࡇ࡜ࡀุ᫂ࡋࡓሙྜࡣࠊධᏛチྍࢆྲྀࡾᾘࡍࡇ࡜ࡀ࠶ࡿࠋ
If it is discovered that an applicant has made false statements or has neglected matters to be stated on this curriculum vitae, the admission may
be revoked even after enrollment.

㹙᪥ᮏᅾఫ㐃⤡ே㹛እᅜᅾఫࡢ᪉ࡢࡳグධࡋ࡚ࡃࡔࡉ࠸ࠋ For applicants living overseas, please fill out a contact person in Japan (if any).
Ặྡฟ㢪⪅࡜ࡢ㛵ಀFull NameRelationship to the applicantఫᡤAddress㟁ヰ␒ྕ㟁Ꮚ࣓࣮ࣝ

Phone:Email:Japan Advanced Institute of Science and Technology     㸦ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝࣭⼥ྜ⛉Ꮫඹྠᑓᨷ㸧ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ
ͤཷ㦂␒ྕ      ᚿᮃ⌮⏤᭩    グධ࡟࠶ࡓࡗ࡚ࡢὀព㸸      ༤ኈ๓ᮇㄢ⛬࣭ಟኈㄢ⛬ᅾᏛ୰࡟⯆࿡ࢆࡶࡗࡓ◊✲ࡸྲྀࡾ⤌ࢇ࡛ࡁࡓ◊✲ࠊᚓព⛉┠ࠊᮏᏛධᏛᚋࡢᢪ㈇ཬࡧ኱Ꮫ㝔ಟ஢ᚋ࡟ά㌍ࡋࡓ࠸ศ㔝࡞࡝࡟ࡘ࠸࡚ᯟෆ࡟཰ࡲࡿࡼ࠺࡟グ㏙ࡍࡿࡇ࡜㸦⮬⏤グ㏙㸧ࠋ   Ặ ྡ㸸㸦እᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධ㸧໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉⼥ྜ⛉Ꮫඹྠᑓᨷ