A2,B2
令和７年度(4⽉⼊学) 名古屋⼤学⼤学院⼯学研究科博⼠後期課程⼊学志願票
Application Form for Admission to Doctoral Program, April 2025 Entrance

志

望

専

(Department)

攻

受験番号（記⼊しない）（Name of Department in which

Application No.

you wish to study)（Do not fill in)

ふりがな (Furigana)
⽒

名(Name)［注］漢字で記⼊すること。漢字⽒名の無い外国籍の学⽣は，英字で姓，名，ミドルの順に記⼊すること。
Note)Write in Kanji(chinese character). For international students who do not have a name in Kanji, write in English in the order of family name, first name, middle name.

志望指導教員⽒名（Name of the faculty member
you wish to have as your advisor)

修⼠論⽂題⽬（Title of Master Thesis)［注］修⼠課程を修了⾒込みであり, 修⼠論⽂題⽬が未定の場合は，「未定」と記⼊すること。
Note) If you are expected to complete a master's program and the title of your master's thesis is undecided, write "Undecided."□TOEIC

スコアシート提出（Score Sheet to be submitted）□TOEFL iBT□不提出(Do not submit)（※いずれかの□にレ点）Please check one.

試験実施⽇(Examination Date)：⻄暦

年(Y)

⽉(M)

⽇(D)

［注］スコアシートを提出する必要のある専攻については，要項を確認すること。
Note) Refer to the Application guideline for the departments requiring score sheet to be submitted.

出願資格［

出願資格
(Eligibility Requirements)

Eligibility Requirements］（←１〜8を記⼊。募集要項参照）
Write 1〜8. Refer to the Application guideline.

履
年⽉（⻄暦）

(M)

年

⽉

年

⽉

年

⽉

年

⽉

年

⽉

事

⾼
等
学
校
卒
業
以
︶

降

Employment Background

職
歴

Backgroud

項（⾼等学校卒業から順に記載すること。）
⾼等学校卒業(Completion from High School)

⼤学(University or Collegee)

歴︵

Educational Background

学

(Y)

歴

⼤学
(University or Collegee)

⼤学⼤学院(University or Collegee)

⼤学⼤学院(University or Collegee)

学部(School)

学科(Department)

学部

学科(School)(Department)

研究科(Graduate School)

専攻(Department)

研究科(Graduate School)

専攻(Department)

⼊学(Entrance)

卒業(Completion)

⼊学(Entrance)
修了・修了⾒込(Completion/Expected for completion)※上記以外の学歴がある場合は，以下に記⼊すること。If you have an educational background other than the above, please fill in the following.
⽇本国内の⽇本語教育機関等についても，以下に記載すること。Please also describe the Japanese language education institution in Japan below.

年

⽉

年

⽉

年

⽉

年

⽉

年

⽉

年

⽉

年

⽉

年

⽉

※職歴が無い場合は，１⾏⽬の事項欄に無しと記⼊すること。
Note) If you do not have any Employment Background, please write "none" in the item column on the ﬁrst line.

⼊学(Entrance)

⼊学(Entrance)

A5,B5
受験番号（記入しない）

修士論文又は研究経過の概要(Do not fill in)(Summary of Master’s Thesis or Research Work)
№
ふ

志望専攻
(Department)

り

が

氏

１

な

名
(Name)（名古屋大学大学院工学研究科）(Graduate School of Engineering, Nagoya University)

本様式に2,000字程度（英語であれば1,000語程度）で作成すること。
なお，パソコン使用の場合は本様式（Ａ４版）にならい１行40字程度で作成すること。

(Summarize your Master’s thesis or research work in about 2,000 characters in Japanese or 1,000 words in English.
If you use a computer, set a line to be about 40 characters and attach each page of your printouts to this form.)

A5,B5
受験番号（記入しない）

修士論文又は研究経過の概要(Do not fill in)(Summary of Master’s Thesis or Research Work)
№
ふ

志望専攻
(Department)

り

が

氏

２

な

名
(Name)（名古屋大学大学院工学研究科）(Graduate School of Engineering, Nagoya University)

本様式に2,000字程度（英語であれば1,000語程度）で作成すること。
なお，パソコン使用の場合は本様式（Ａ４版）にならい１行40字程度で作成すること。

(Summarize your Master’s thesis or research work in about 2,000 characters in Japanese or 1,000 words in English.
If you use a computer, set a line to be about 40 characters and attach each page of your printouts to this form.)

A6,B7

TOEFL／TOEIC

スコアシート提出⽤紙〇TOEFL の場合この枠内に， “TestTaker(Examinee)Score Report” のコピーを貼付し，出願時に提出すること。
なお、“Institutional Score Report” ⼜は “Official Score Report” も提出期限までに名古屋⼤学へ到着するよう，⼿続きを⾏うこと。
“Test Taker(Examinee)Score Report” と “Institutional Score Report” ⼜は “Official Score Report” のいずれか⼀⽅でも期限までに到着しなかった場合，スコアシートの提出はなかったものとして扱う。

〇TOEIC の場合“Official Score Certificate” （原本に限る。コピーは不可とする。）の上１／４を切り取り，この枠内に貼付し，出願時に提出すること。
（下３／４は提出不要。）

受験番号・⼀度提出したスコアシートの返却，差し替えおよび写しの返却には応じられない。

◎以下は必ず記⼊してください。
⽒

名：

志望専攻名：

専攻

A9,B10
様式１

Declaration of applicable specific categories

If you are applying to Nagoya University as a faculty member or student, we ask you to declarewhether you are subject to “deemed exports” controls under the Foreign Exchange and Foreign Trade
Act (“FEFTA”).
Please refer to the attached flowchart for your position, check the appropriate boxes, and submit ittogether with your application form and documents.

Department

Graduate School of Engineering

Name□ Category 1 applies □ Category 2 applies □ Category 3 applies □ No categories apply
If you fall into one of the Categories 1 to 3, please provide a reason below and submit the relevant
evidence.
Reason for applicability(e.g., employed by __ institution, receiving funding/scholarship from __, or planning to do so)（）

Evidence(e.g., proof of employment by a foreign organization (letter of employment/contract), letter of funding
from a foreign organization (individual), notice of scholarship award or application form)（）*Please contact us if you are unsure whether any of the above categories apply.
Academic Research & Industry‐Academia‐Government collaboration
E-mail：anzen@aip.nagoya-u.ac.jp

TEL：052-747-6702

ExportControl

Division

Note)

If the application falls under any of the categories 1 to 3,
submit this flow card along with Declaration.

様式１

Attachment
Flowchart for Determining Applicable Categories

B6〔博士後期課程社会人特別選抜用〕〔Special Admission for Working Applicants〕
受 験 番 号※

(Application No.)

※印欄には記入しないでください。

受 験 承 諾 書
(Approval for application)

氏

名(Name)

生年月日(Date of Birth)

年(Year)月(Month)日(Day)

上記の者が，令和７年度名古屋大学大学院工学研究科博士後期課程の入学試験を受験す
ることを承諾し，合格のうえは課程修了までの期間通学することを認めます。
This is to certify that I consent the person above sit for the admission examination and remain dedicated tostudies upon entry to the Doctral Program of the Graduate School of Engineering, Nagoya University,in April 2025.

（西暦）年(Year)月(Month)日(Day)

名古屋大学大学院工学研究科長

殿(To the Dean of Graduate School of Engineering, Nagoya University)

所

在

地

(Address of the Office)

機

関

名

(Name of Organization)

役

職(Position)

所属長又は代表者氏名印(Certifier)㊞(Signature)※所属機関の代表者又はこれに代わる上司等が証明すること。

Note: The Certifier must be a representative or an appropriate supervisor of the organization.

514円分の切手をお貼り
ください。

-速達-

A7,B8

特定記録

514

①カラーで印刷してください。
②「宛名ラベル」を切り取り線にしたがって、ハサミ等で切り取ってください。
③住所・氏名・郵便番号を記入してください。（日本国内の住所に限る）④市販の長形 3 号の封筒（120mm × 235mm）に貼り付けてください。
（郵送中に剥がれてしまうことの無いよう、強くのり付
けしてください。）⑤「宛名ラベル」に必要な切手をのりで貼付してください。

① Please print this label in color.
② Along the cut line, cut it with scissors etc.
（……切り取り線……=cut line）③ Please write address in right space (Only the address
in Japan), your name on the above of < 殿 >, zip code in□ □□ ‐ □□□□ .
④ Please prepare standard "3 号 " envelope (Size:120mm
× 235mm), and paste each label. Paste strongly not tocome off. Please make arrangement these envelopes tobe able to receive in Japan.
⑤ Please paste necessary stamps by glue in the column
for pasting postage stamp.

-速達特定記録

切り離して下さい

・カラーで印刷してください。
・住所・氏名・郵便番号を記入してください。( 日本国内の住所に限る）
・市販の角型２号の封筒（縦 332mm ×横 240mm）に貼り付けてください。
（郵送中に剥がれてしまうことの無いよう、強くのり付けしてください。
）
・この用紙を貼り付けた封筒は、２つ折りにして、出願書類に同封してください。
・令和７年３月頃に書類を受け取ることができる住所を記載してください。

A8,B9

出願資格(7)による出願資格事前審査願(Application form for preliminary examination by "Eligibility Requirement (7)")

令和７年度名古屋大学大学院工学研究科博士後期課程に「出願資格(7)」により出願したいので，同資格の事前審査をお願いします。
I would like to take the preliminary examination by "Eligibility Requirement (7)" in oreder to apply for the admission to the
HAKUSHI-KOKI-KATEI (DOCTORAL PROGRAM) of the Graduate School of Engineering at Nagoya University.

（西暦）年(Year)月(Month)

日
(Day)

氏名

,

(Name)(Family Name)（自筆署名）,(First Name)(Middle Name)(Signature)

住所・電話番号 (Address, Telephone number)〔〒℡〔E-mail〕〕

志望専攻名 (Name of the department in which you wish to study)〔

専攻〕(Department)

卒業大学・学部・学科名 (University or college of graduation)
〔

大学

学部

(University or College)

学科〕(School)(Department)

卒業年月日 (Date of graduation)〔西暦年(Year)月(Month)

日

卒業〕

(Day)

現職等（所属機関・部署・職名等）(Present status (Organization, Department, Position))〔℡〕

職務内容等・期間 (Type of work, period of employment)〔〕

〔博士後期課程出願資格(7)による事前審査用〕〔Application for preliminary examination by "Eligibility Requirement (7)"〕〔博士後期課程出願資格(8)による個別審査用〕〔Application for individual screening by "Eligibility Requirement (8)"〕

研究歴証明書(Certificate for Academic Background)（西暦）年(Year)

月日(Month)(Day)

証明者(Certifier)

〔所

属〕 〔職

(Affiliation)

名〕 〔氏(Title)名〕(Name in full)㊞(Signature)
ふ

り

が

氏

な

名

男・女

(Name)

生

年

月

西暦

日

(Date of Birth, Age)

年

月

日生（

(Year)(Month) (Day)

歴

事

歳）

(Male･Female)(Age)

現職等（所属・職名等）
Present status(Organization,Department, Position)

現

住

所

(Address in Japan)〒
研

年 月 日（西暦）究Year / Month / Day

大学(University or College)

備項(Academic Background after Graduation)

学部(School)

学科(Department)

卒業(Graduation)

考(N. B.)

注(1) 志願者を熟知する所属の長，又は指導的立場にある者が証明すること。
(2)

年齢は，令和6年7月1日現在で記入すること。

Note (1) The Certifier must be a representative or an appropriate supervisor of the organization to which the applicant has
been attached.
(2) Age is as of July 1, 2024.

〔博士後期課程出願資格(7)による事前審査用〕〔Application for preliminary examination by "Eligibility Requirement (7)"〕

推

薦

書

(Letter of Recommendation)
（西暦）

年
Year

名古屋大学大学院工学研究科長

月
Month

日
Day

殿

(To the Dean of Graduate School of Engineering, Nagoya University)

推 薦 者(Reference)

〔

所

属

〕・〔

職

(Affiliation)

名(Title)

〕・〔

氏

名

〕

(Name in full)㊞(Signature)◎志願者の研究分野と将来の希望及び素質，性格等についてのご意見を，また，志願者との関係についても下欄にご記入下さい。
（ご記入後は厳封願います）(◎To Reference; Please write your opinion about the research area, the plan for the future, abilities, personal character of the applicant and therelationship to the applicant as well. Please seal the form in the envelop after filling it out.)
ふ

志望専攻(Name of the department in which the applicant wishes to study)

り

が

氏

な

名
(Name)

Family name, First name, Middle name(注)志願者を熟知する所属の長，又は指導的立場にある者が記入・証明すること。
(Note: The Reference must be a representative or an appropriate supervisor of the organization to which the applicant has been
attached.)

〔博士後期課程出願資格(7)による事前審査用〕〔Application for preliminary examination by "Eligibility Requirement (7)"〕〔博士後期課程出願資格(8)による個別審査用〕〔Application for individual screening by "Eligibility Requirement (8)"〕

研究実績調書(Bibliography)
志 望 専 攻(Name of thedepartment in which
you wish to study)
ふ

り

が

氏

専攻
現 職 等

な

（所属職名等）

Present status(Organization,
Department,
Position)

名(Name)

生年月日（年齢）(Date of Birth, Age)

西暦

年

月

日（

所 在 地
(Office Place)連 絡 先(Phone Number)

現 住 所歳） (Address

学術論文題名，著書，学協会，討論会，国際会議等での研究発表題名，及び特許・発明等の名称(Title of scientific paper, publication, conference presentation,patent, invention, etc.)

in Japan)

TEL

発表論文誌の名称，巻，頁，発表年（印刷中または投稿中の場合は，その旨を記
著者入すること）（本人を含め記載(Journal volume, pages and published year (If the
順に記すこと）paper is in press or so, write the situation.))
発表学協会，討論会，国際会議等の名称及び発表年月日(Name of the conference etc. and the date ofpresentation.

注(1) 学術論文等は，別刷又はその写しを添付し，研究発表の場合は，要旨又は概要を添付すること。
(2)

この用紙に書ききれない場合は，同様の形式のものを付加してもよい。

(3)

年齢は，令和6年7月1日現在で記入すること。

Note (1) Attach one reprint or photocopy of each paper or abstract of each conference presentation.
(2) You may add similar forms if the space of this form is not enough.
(3) Age is as of July 1, 2024.

TEL

Author(s)(Write all authors,
including you, inlisted order.)〔博士後期課程出願資格(7)による事前審査用〕〔Application for preliminary examination by "Eligibility Requirement (7)"〕〔博士後期課程出願資格(8)による個別審査用〕〔Application for individual screening by "Eligibility Requirement (8)"〕

研究成果報告書(Summary of Research)
№
ふ

り

が

氏

志望専攻
(Name of the department in which you wish to study)

な名(Name)

本様式に日本語の場合は4,000字程度,英語の場合は1500語程度で作成すること。なお，パソコン使用の場合は本様式（Ａ４版）にならい
１行40字程度で作成すること。
(Summary of research results should be approximately 4,000 characters in Japanese or 1,500 words in English. If you use acomputer, set a line to be about 40 characters and attach each page of your printouts to this form.)

（西暦）

年

月

日

出願資格(8)による出願資格個別審査願(Application form for individual screening by "Eligibility Requirement (8)")

名古屋大学大学院工学研究科長

殿(To the Dean of Graduate School of Engineering, Nagoya University)

専攻へ

令和７年度名古屋大学大学院工学研究科博士後期課程(Department)「出願資格(8)」により出願したいので，同資格の個別審査をお願いします。

I would like to take the individual screening by "Eligibility Requirement (8)" in order to apply for the admission to the
HAKUSHI-KOKI-KATEI (DOCTORAL PROGRAM) of the Graduate School of Engineering at Nagoya University.

氏

名

，

(Name)

Family Name ,生年月日 (西暦)(Date of Birth)

住（自筆署名）

所

年(Year)〒(Address)

Ｔ Ｅ Ｌ：

Ｅ-ｍａｉｌ：－Middle Name (Signature)

First Name

月

日生〔満

(Month) (Day)

歳〕
(Age)

〔博士後期課程出願資格(8)による個別審査用〕〔Application for individual screening by "Eligibility Requirement (8)"〕

履 歴 書

（西暦）

(Resume)

年(Year)月(Month)

日

現在

(Day)

ふりがな

氏

性

名

あ

(Name)

Family Name,

生年月日（西暦）First Name,

年(Date of Birth)(Year)

年 (西暦)

月(Year)(Month)年 (西暦)

月(Year)(Month)月(Month)学(自筆署名)

あMiddle Name

日
(Day)

生（満

(Signature)

別男・女(Male/Female)

歳）
(Age)

歴 （入学・転学・卒業・退学等についてすべて記入のこと）(Educational Background)職

歴 （就職・退職についてすべて記入のこと）(Employment Record,begin with the most recent one if any)

（次頁へ続く）年 (西暦)月(Year)(Month)研究歴 （研究開始・終了についてすべて記入のこと）(Research Career)業績 （学術論文・著書・研究発表・特許・作品等）

年 (西暦)

月(Year)(Month)(Research Resume (Published research papers or books, research presentations, or patents held))

年 (西暦)

月(Year)(Month)免許・資格等(License, Qualification)

記入上の注意：１．鉛筆以外の黒又は青の筆記具で記入すること。
２．数字はアラビア数字で，文字はくずさず正確に書くこと。
３．書ききれないときは，様式を複写して使用すること。

A12( 1 out of 2 )Application Number*
Please do not fill in the fields marked with *AY 2025 (April Entrance) Nagoya University Graduate School of Engineering Doctoral Program
Application Document Checklist (Regular Admission)
Desired Department

Furigana
Name・Check the documents to be submitted carefully, enclose the application documents in the order of the list
below (with the Application Form at the top) and mail it.
・Please put a ✔ mark in the corresponding “Applicant check box” if the document has been included in thesubmission package.
・Please draw a slash (/) in the check box if the document does not need to be submitted.

Who should Submit

How to Obtain
Download
Downloadfrom thefrom thePrepare on
GraduateWeb
your own
School of
application
Engineeringsite
websiteDocuments to besubmitted (the numbers
below correspond to theapplication guidelines)All

A1) Nagoya University
Graduate School
Application Form〇〇

A1) Photograph Card〇〇

A2) Application Form for
Admission to Doctoral
Program (designated
form)

〇

A3) Academic transcript
for undergraduate andmaster's programs(original)

A4) Certificate ofcompletion (or expectedcompletion) of a master's
program or professional
degree program (original)

A5) Summary of Master's
Thesis or Research Work(designated form)

A6) TOEFL or TOEIC
score sheet (stick todesignated form)

Applicable
persons only

Comments

Applicantcheck box

University
check box〇〇

Please referto theapplication
guidelines
about who
does notrequiresubmission.

〇〇

Please referto theapplication
guidelines
about who
does notrequiresubmission.

〇

〇

〇

Please referto theapplication
guidelines
about who
does notrequiresubmission.
Please referto theapplication
guidelines
about
applicabledepartments.

〇〇(Stick results
to designated
form)

〇

Continued on 2nd page

A12
( 2 out of 2 )Application Number*
Please do not fill in the fields marked with *AY 2025 (April Entrance) Nagoya University Graduate School of Engineering Doctoral Program
Application Document Checklist (Regular Admission)
Desired Department

Furigana
Name・Check the documents to be submitted carefully, enclose the application documents in the order of the list
below (with the Application Form at the top) and mail it.
・Please put a ✔ mark in the corresponding “Applicant check box” if the document has been included in thesubmission package.
・Please draw a slash (/) in the check box if the document does not need to be submitted.

Who should Submit
Documents to besubmitted (the numbers
below correspond to theapplication guidelines)

All

Applicable
Comments
persons only〇

Unnecessary
for thoselivingabroadA8) Envelope for
notification of enrollment
procedures (attach
designated form)〇

Unnecessary
for thoselivingabroadA9) Declaration ofApplicable SpecificCategories(designated form)〇

A7) Envelope for
notification of acceptanceor denial of application(attach designated form)

A10) (Foreigners only)
Copy of both sides of your“Residence Card” ororiginal of your “Copy of
Certificate of Residence”
A11) Certificate ofJapanese Government
Scholarship (original)A12) Application
Document Checklist(designated form)

Final Check〇

How to Obtain
Download
Downloadfrom thefrom theGraduate
Prepare on
Web
School ofyour own
application
Engineeringsite
website〇(Attachdesignated
form)

〇

〇
(Attachdesignated
form)

〇

〇

〇

Foreigners
only

〇

〇

Japanese
Government
Scholarshipstudents
only

〇

〇

Are the downloaded documents printed out in color on A4 size paper?
Have you printed out in color the "Address sheet for the envelope forsending application documents" posted on the Graduate School ofEngineering website and pasted it on Kaku 2 envelope (24cm x 33.2cm)?
Have you checked all the documents for any omissions and put them in
the above envelope?

Applicantcheck box

University
check box

B13
( 1 out of 2 )Application Number*
Please do not fill in the fields marked with *AY 2025 (April Entrance) Nagoya University Graduate School of Engineering Doctoral Program
Application Document Checklist (Special Admission for Working Applicants)
Desired Department

Furigana
Name・Check the documents to be submitted carefully, enclose the application documents in the order of the list
below (with the Application Form at the top) and mail it.
・Please put a ✔ mark in the corresponding “Applicant check box” if the document has been included in thesubmission package.
・Please draw a slash (/) in the check box if the document does not need to be submitted.

Who should Submit

How to Obtain
Download
Downloadfrom thefrom thePrepare on
GraduateWeb
your own
School of
application
Engineeringsite
websiteDocuments to besubmitted (the numbers
below correspond to theapplication guidelines)AllB1) Nagoya University
Graduate School
Application Form〇〇

B1) Photograph Card〇〇

B2) Application Form for
Admission to Doctoral
Program (designated
form)

〇

B3) Academic transcript
for undergraduate andmaster's programs(original)〇

B4) Certificate ofcompletion (or expectedcompletion) of a master's
program or professional
degree program (original)〇

B5) Summary of Master's
Thesis or Research Work(designated form)〇

B6) Approval for
application(designated form)

Applicable
persons only

Comments

Applicantcheck box

University
check box〇
Please referto theapplication
guidelines
about who
does notrequiresubmission.
Please referto theapplication
guidelines
about who
does notrequiresubmission.
Please referto theapplication
guidelines
about who
does notrequiresubmission.

〇

〇

〇

〇

Continued on 2nd page

B13
( 2 out of 2 )Application Number*
Please do not fill in the fields marked with *AY 2025 (April Entrance) Nagoya University Graduate School of Engineering Doctoral Program
Application Document Checklist (Special Admission for Working Applicants)
Desired Department

Furigana
Name・Check the documents to be submitted carefully, enclose the application documents in the order of the list
below (with the Application Form at the top) and mail it.
・Please put a ✔ mark in the corresponding “Applicant check box” if the document has been included in thesubmission package.
・Please draw a slash (/) in the check box if the document does not need to be submitted.

Who should Submit

Documents to besubmitted (the numbers
below correspond to theapplication guidelines)AllB7) TOEFL or TOEIC
score sheet(stick to designatedform)B8) Envelope for
notification of acceptanceor denial of application(attach designated form)
B9) Envelope for
notification of enrollment
procedures (attach
designated form)B10) Declaration ofApplicable SpecificCategories(designated form)B11) (Foreigners only)
Copy of both sides of your“Residence Card” ororiginal of your “Copy of
Certificate of Residence”〇

Final Checktheapplication
guidelines
about
applicabledepartments.

〇

Unnecessary
for thoseliving abroad〇

Unnecessary
for thoseliving abroad〇B12) Certificate ofJapanese Government
Scholarship (original)B13) Application
Document Checklist(designated form)

How to Obtain
Download
Downloadfrom thefrom theApplicable
Graduate
Prepare on
Comments
Web
persons only
School ofyour own
application
Engineeringsite
website〇Please refer to〇(Stickresults todesignatedform)〇(Attachdesignatedform)〇(Attachdesignated
form)

〇

〇

〇

〇

〇

Foreigners
only

〇

〇

Japanese
Government
Scholarshipstudents only〇〇

Are the downloaded documents printed out in color on A4 size paper?
Have you printed out in color the "Address sheet for the envelope forsending application documents" posted on the Graduate School ofEngineering website and pasted it on Kaku 2 envelope (24cm x 33.2cm)?
Have you checked all the documents for any omissions and put them in
the above envelope?

Applicantcheck box

University
check box