For an applicant who needs a "letter of acceptance"
before admission procedure, in order to apply to scholarships :Please follow the instruction below.
The decision to issue the "letter of acceptance" will be made based on screening
by academic records, related documents, and interview. Note that, for enrollment,
the applicant is requested to pass the entrance examination conducted by theintended department after he/she receives the "letter of acceptance."
1. Please have a contact with your intended academic adviser at Tokyo Tech in your email,and send a carbon copy(CC) to Interdisciplinary Science and Engineering Group (ipise@jim.titech.ac.jp).
2. Please send the following required documents to the intended advisor by airmail.
(See below)
3. Please take the interview conducted by the intended department (direct or internet interview).

*! Important Note !* : It needs about 2-3 months to issue a "letter of acceptance" after the request,
since above preliminary screening is required.
For inquiries or more information,please contact to the intended advisor or contact person of the intended department.
The required documentsa) The applicant's personal information. (use attached form)b) Statement of purpose, and Study plan at the intended department.
c) Official academic transcripts from each undergraduate and graduate school(photocopied).
d) Certificate of graduation or expected graduation from each undergraduateand graduate school(photocopied).
e) Summary of Master's thesis.
*If you do not have a Master's thesis, please write and submit the detailsof your Master's program study.
f) English Proficiency Test(photocopied)*Scores from TOEFL-iBT, TOFEL-PBT, TOEIC or the IELTS academic module taken
within two years are recommended.
g) One copy of the applicant's passport (page showing name, nationality and photo),or one copy of the applicant's photo.
h) etc. (by request of the intended academic advisor / department).

Registration Form for "Letter of Acceptance" (Personal Information Form),
Interdisciplinary Graduate School of Science and Engineering,Tokyo Institute of Technology（東京工業大学大学院総合理工学研究科「受入内諾書」発行申請）
INSTRUCTIONS（記入上の注意）
１．The form should be typed if possible, or neatly handwritten in block letters. （明瞭に記入すること｡)
２．Numbers should be in Arabic numerals.（数字は算用数字を用いること｡)
３．Years should be written using the Anno Domini system. （年号はすべて西暦とすること｡)
４．Proper nouns should be written in full and not abbreviated. （固有名詞はすべて正式な名称とし，一切省略しないこと｡)* Personal data entered in this application will only be used for issuing "letter of acceptance."(本申請書に記載された個人情報については，受入内諾書を発行するため以外には使用しません。
）(Sex)
１．Name in full in English（姓名（英語表記))□Male（男），(Family name)(First name)(Middle name)□Female（女）（Write your name exactly same as is printed in your passport）※ Possesion of Japanese nationality

２．Nationality（国 籍）□Yes, I have.（はい）□No, I don’t have it.(いいえ)３．Date of birth(生年月日）
19Year（年）Month（月）Day（日）

Age（年齢）４．Present status with the name of the university attended or employer（現職（在学大学名又は勤務先名まで記入すること｡））

５．Present address and telephone number, facsimile number, e-mail address（現住所及び電話，ファックス番号，E-mail アドレス）
現住所(Present address）：
電話番号/FAX 番号(Telephone/facsimile number）：
E-mail address：* If possible, write an e-mail address that can be used for periods including the time before you come to Japan, your stay in Japan and the period after
you return home.
（可能な限り、渡日前～日本留学中～帰国後にわたり使い続けることが予想される E-mail アドレスを記入すること。
）

６．Field of specialization studied in the past（Be as detailed and specific as possible.)（過去に専攻した専門分野（できるだけ具体的に詳細に書くこと｡））－1－

７．Educational background （学歴）Name and Address of School（学校名及び所在地）

Year and Monthof Entrance andCompletion(入学及び卒業年月)

Amount of timespent at theschool attended（修学年数）Name(学校名)

From（入学）

years
（年）

Location
(所在地)

To
（卒業）

andmonths（月）

Name(学校名)

From（入学）

years
（年）

Location(所在地)

To（卒業）

andmonths
（月）

Name
(学校名)

From（入学）

years
（年）

Location(所在地)

To（卒業）

andmonths
（月）

Name
(学校名)

From（入学）

years
（年）

Location(所在地)

To（卒業）

andmonths
（月）

Name
(学校名)

From（入学）

years
（年）

Location
(所在地)

To
（卒業）

andmonths（月）

Diploma or Degree awarded,Major subject（学位・資格，専攻科目）
When taking leave of absence, theperiod and reason.
（休学した場合はその期間・理由）

Elementary Education(初等教育)
Elementary School（小学校）

Secondary Education（中等教育）
Lower Secondary School（中学）

Upper Secondary School（高校）

Higher Education（高等教育）
Undergraduate Level（大学）

Graduate Level（大学院）Total years of schooling mentioned above（以上を通算した全学校教育修学年数）

years
（年）

* If the blank spaces above are not sufficient for the information required, please attach a separate sheet．
((注) 上欄に書ききれない場合には，適当な別紙に記入して添付すること｡)
８．State the titles or subjects of books or papers (including graduation thesis authored by the applicant), if any, with the name and address of the publisher andthe date of publication.（著書，論文（卒業論文を含む｡）があればその題名，出版社名，出版年月日，出版場所を記すこと｡）－2－

９．Employment Record: Begin with the most recent employment, if applicable.（職歴）
Name and address of organization

Period of employmentPosition

Type of work

（勤務先及び所在地）（勤務期間）（役職名）（職務内容）

FromToFromTo10．Japanese language proficiency: Evaluate your level and insert an X where appropriate in the following blank space.
（日本語能力を自己評価のうえ，該当欄に×印を記入すること｡）
Excellent（優）Good（良）

Fair（可）Poor（不可）Fair（可）Poor（不可）Reading（読む能力）
Writing（書く能力）
Speaking（話す能力）* Official test scores to show Japanese language proficiency (If any; ; Score, name of test, and date of issue) :11．English language proficiency: Evaluate your level and insert an X where appropriate in the following blank space.
（英語能力を自己評価のうえ，該当欄に×印を記入すること｡）
Excellent（優）Good（良）

Reading（読む能力）
Writing（書く能力）
Speaking（話す能力）* Official test scores to show English language proficiency (If any; Score, name of test, date of issue ) :12．Intended academic advisor, department, course/program, and period of enrollment.
Academic advisor：
Intended Department：
Study Program (Choose one) :□Regular Program (learn in Japanese)□International Graduate Program (learn in English)
Study Course (Choose one) :□Master's Course□Doctoral Course

Period of Enrollment : From13．Purpose (Usage) of the letter of acceptance.

to（「受入内諾書」の利用目的）

Date of registration（申請年月日）Applicant's signature:（申請者署名）－3－（志望するプログラム／課程，専攻，教員と期間）

（別紙）(attached sheet)

Checksheet□ Applicant's personal data

□ Statement of purpose, and Study plan at the intended department□ Official academic transcripts from each undergraduate and graduate school (photocopy)□ Certificate of graduation or expected graduation from each undergraduate and graduate school(photocopy)□ Summary of Master's thesis□ English Proficiency Test(photocopy)□ One copy of the applicant's passport (page showing name, nationality and photo),or one copy of the applicant's photo

－4－

（別紙）
(attached sheet)

１

Statement of purpose（志望動機）

－5－

２

Study plan at the intended department in detail（志望専攻における研究計画（詳細に記入すること）｡）－6－