Date:

To the Dean of the School/
Graduate School of Economics
Name:(Hiragana)Name:(Chinese Characters)
Name:(English Alphabet)
Date of Birth:

Application Form for Research Students
I hereby apply for admission as a research student as indicated below.
Your kind consideration will be greatly appreciated.

1. Research Theme

2. Term of Research

3. Supervisor’s Signature:

From:

day

monthyear

To:

day

monthyear

RESUME
Name

Date:

Nationality(Hiragana)Name

Photo(Home Language)

SexName(Male/Female)

4cm high x 3cm wide

(English Alphabets)

Date of BirthDay

MonthCurrent Address (Postal code:

Year(Age:)
Tel     )

E-mailAddress for receiving Admission Permit (Leave blank if same as above)TelE-mail

1. Education Background
Educational

Education History

InstitutionPrimary

FromToSchoolDiploma or Degree awarded:

MiddleFromSchool

Diploma or Degree awarded:To

High School FromTo

Diploma or Degree awarded:
University

FromToMajor, Diploma or Degree awarded:

2. Employment Record
Day Month Year

Details㸦Name of the Organization, positon and type of work㸧

FromTo13FromTo
FromTo3. Japanese Learning Background
Day Month Year

Institution NameFromToFromTo
FromTo㸲㸬Defrayer’s/sponsor’s Information and Applicant’s Future Plan
Defrayer’s/Sponsor’sinformation
Term you wish to‫ ڧ‬Only a research student term

study in Kyushu‫ ڧ‬Through to the completion of master’s degree program

University‫ ڧ‬Through to the completion of doctoral program

5. Other personal information
Favorite Subjects

Health Condition

Hobbies

License or qualification

Favorite Sports

Other

6. Family members (Please mark “ࠐ” if your family member is residing in Japan㸧
Name

Relationship

AgeNameRelationship

Age14

PHYSICAL EXAMINATION CERTIFICATE□Male □FemaleName:

Sex:

Date of Birth:

Nationality:

Receipt Number

Current Address:
Height:cm

Eyesight:
With glasses:

Weight:

(R)
(R)

(L)
(L)

□ Normal□ NormalHearing:(R)(L)

Speech:□ Normalkg*Office use only

□ Abnormal□ Abnormal□ Abnormal

If yes, please describe□ Yes

Functional disorders of extremities:□ No

If yes, please describe
Other illness or disorders:

□ Yes

□ No

If yes, please describe□ Yes

Past illness:□ No

If yes, please describe

Urinalysis:

HBs:

Protein
Sugar
Urobilinogen

Antigen
Antibody－－－－－/Blood type:，RH:□Direct＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋

Blood Pressure:

Chest X-ray:＋＋＋mmHG□Indirect

Please comment on condition of applicant’s lungs, giving date of tests:

Please describe in detail any disease (chronic or other) or physical handicaps:

Please indicate past illness:

Are there any physical or mental conditions that may limit the student's ability to study?
□ Yes
□ No
Does the student have any food or drug allegies? If "Yes", please describe.
□ Yes□ NoDo you consider the student to be in adequate mental and physical health for full andsucessful participation in the study abroad program?
□ Yes (Adequate)□ No (Inadequate)
If "No", please describe the reason.

I diagnose, that the applicant’s healthy and physical condition are:□ Excellent□ Good□ Fair
□ PoorI hereby certify the above diagnosis
Physician’s Signature:
Name of Hospital:
Address:
Date of Examination:(Hospital Stamp)

Letter of Guarantee
Date:

Guarantor
Name(Chinese characters） Name(English Alphabet）

Country

Date of BirthSex(Male/Female)

Nationality Relationship to ApplicantCurrent Address
Detailed Address

Postal CodePhone Number

As the applicant's guarantor, I hereby certify that I take full responsibility to pay any and all costs
resulting from the applicant's misconduct, tuition fees, and school expenses, and any other debts incurred
during his/her attendance period at your university.

ApplicantExpected Enrollment Date

School/Graduate School of Economics

Name（Chinese characters） Name（English Alphabet） Date of BirthCountry

Current Address
Detailed Address

Sex(Male/Female)

Nationality

Postal CodeNote: 1. In principal, a guarantor must be a parent, or a brother or sister of the applicant.
2. The change of guarantor should be reported quickly to the dean of the school/gruaduate school.
3. This form must be filled out in the guarantor's own handwriting.

Phone Number

KYUSHU UNIVERSITY
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Click "Examination Fee".

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2. Terms of Use andPersonal Information
Management

Click "Agree" button located in the lower part of this page if you agree with these terms.
Click "Not agree" button located in lower part of this page if you do not agree with these terms.

3. School Selection

Select “Kyushu University (Undergraduate Schools) ” or “Kyushu University (Graduate Schools).”

4. School Information

Read the information carefully and click "Next".

5. Category Selection

Choose First to Fourth Selection and add to Basket.

6. Basket Contents

Check the contents and if it is OK, click "Next".

7. Basic Information

Input the applicant's basic information.
Choose your credit card and click "Next".

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Input Credit Card Number (15 or 16-digits) ,Security Code and Expiration date.
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Follow the onscreen instructions to complete the card payment.
Please click the “Application Results” button in the upper
part of this site (e-shiharai.net).
↓Please write down the “Receipt Number” given when you
complete your application, and enter your“Payment Method”, “Receipt Number” and “Birth Date”.
Please make sure your printer is ready.
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XXXXXXų

Application

Enclose the printed "Result" page in an application envelope withother necessary application documents.
Necessary application documents
e-shiharai.net

Mail it via post

Result000-0000
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POST OFFICEXXXXXXXXXXXXXXXXXXXXX XXPrint this Page

[NOTICE/FAQ]●You can make a payment anytime, during the payment period mentioned inthe application instructions.
Please refer to the application instructions and complete payment in time.
●Please complete payment by 11:00 pm Japan time, on the last date of thepayment period.
●Please note that refund is not possible once you have made a payment ofApplication fee.

●A fee is added to Examination fee. For further info, please visit our website.
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information page is that of the applicant him/he-self.
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Result page. Please enter "Receipt Number" and "Birth Date" to redisplay.
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