（別記様式－後予１）(For Doctoral Degree by Course Work)

ExampleAcademicAdvisor’s
Seal/Signature

Receive the seal from your academic advisor.

春日

Preliminary Review Application
MM DD, 20XX
A Shachihata seal is not acceptable.
To Dean of Graduate School of Library, Information and Media Studies,

The signature can be substituted for theseal.

Doctoral Program in Library, Information and Media Studies, Graduate
School of Library, Information and Media Studies
Doctoral Program
Academic Year of Enrollment20XX
Name

TSUKUBA Taro

The name of the degree you wish

Student ID Number 20XXXXXXX

Seal/Signature

筑波

Doctoral Degree (○○)

Fill in the name of the degree you wish.
Pursuant to Section 8 of the dissertation review regulations of the Doctoral Program in Library, Information andMedia Studies, Graduate School of Library, Information and Media Studies (Doctoral Degree by Course Work), I
hereby submit the following documents and request the review.
1. Dissertation for preliminary review: 5 copies
2. Abstract of dissertation for preliminary review (Japanese or English): 1 copy
3. Author bibliography : 1 copy
4. Offprints or copies of papers that forms a core of the dissertation: 5 copies each
5. Curriculum vitae: 1 copy
6. Letters of consent: 1 copy each
7.Non-plagiarized dissertation report: 1 copy
8. Ethical review report: 1 copy
Remarks: 1. The applicant shall put his/her name and seal or signature.
2. For the name of the degree, enter one from “Library and Information Studies”, “Informatics” or“Philosophy”, whichever is applicable.
3. For writing the dissertation, be sure to refer the "Degree Application Guide (Doctoral Program)".
4. If there is another reference material for the degree review, submit one copy each.

（別記様式－後予３）

A Shachihata seal is not acceptable.

ExampleSubmitted on MM DD, 20XX

Abstract of Dissertation for Preliminary Review (Japanese)
Graduate School, University of Tsukuba
Graduate School of Library,
Information and Media Studies
Doctoral Program
Title

Student ID
NumberName in

20XXXXXXXXX

KatakanaName

ﾂｸﾊﾞﾀﾛｳTSUKUBA筑波

Taro

Seal/Signature

Title of Dissertation for Preliminary Review
Research on ○ ○ ○OutlineThe outline of the dissertation to be applied, approx.
4,000 characters in Japanese.

〇〇・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・

If there are more than two pages, include“the degree name, student ID, name, title, andseal/signature” shall be described, and also"1/2, 2/2..."shall be printed at the bottom.
Remarks: 1. When writing, be sure to refer the "Degree Application Guide (Doctoral Program)."
2. In the case of a doctoral dissertation, the student ID number is not required.
3.The outline should be approx. 4,000 characters in Japanese.

１／２

（別記様式－後予４）

A Shachihata seal is not acceptable.

ExampleSubmitted on MM DD, 20XX

Abstract of Dissertation for Preliminary Review (English)
Graduate School, University of Tsukuba
Graduate School of Library,
Information and Media Studies
Doctoral Program

Student ID
NumberName in

20XXXXXXX

Katakana

NameTitle

ﾂｸﾊﾞﾀﾛｳTSUKUBA筑波

Taro

Seal/Signature

Title of Dissertation for Preliminary Review (English)

Research on ○ ○ ○The outline of the dissertation to be applied, approx. 1,200
Abstractwords in English.

Ａ・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・・

If there are more than two pages, include“the degree name, name, seal/signature, and the title”
shall be described, and also"1/2, 2/2..." shall be printed
at the bottom.
Remarks: 1. When writing, be sure to refer to "Degree Application Guide (Doctoral Program)."
2. In the case of a doctoral dissertation, the student ID number is not required.
3. The outline will be approx. 1,200 words in English.

１／２

Example（別記様式－後予５）

A Shachihata seal is not acceptable.
Submitted on MM DD, 20XX

Author Bibliography
Graduate School, University of Tsukuba
Graduate School of Library,
Information and Media Studies
Doctoral Program

Student ID
NumberTitle

Name in

20XXXXXXXXX

KatakanaName

ﾂｸﾊﾞﾀﾛｳTSUKUBA Taro筑波

Seal/Signature

Name of Dissertation for Preliminary Review
Research on ○ ○ ○（Research on …）

If the title is in Japanese, the title in English shall be written in ().

And, if the title is in English, the title in Japanese shall be written in (* The title in Japanese is not required for the students enrolled in October.
Core papers of the dissertation
1) Peer-reviewed academic journals
Name, 〇〇, "title of the paper", journal name, volume, issue, year of print, the beginning and the end of pages of

List two or more core papers in the following categories 1)

publicationto 2).
Name, "title of the paper", journal name, volume, issue,Writeyear ofthe
print,
the ofbeginningand the end
pages
namethe categories
fromof 1)
to of2). Write

publication"None" on the blank category.

The core
papersshould betime
writtenfollowing the method〇 Taro Tsukuba, Hanako Tsuchiura, "a study on the wholesolutionof polynomialof constraint
described inthe "Degree Application Guide" in principle.
satisfaction Problem", Journal of the Japanese Society of Population
Intelligence,(However, if it is difficult to follow the described method,Vol. 2, No. 3, 2008, pp. 234-240.

the volume or issue numbers, etc. should be subject to thenotation of the offprints or its copies.)
List all authors, and underline the names of the degreeapplicant.

2) Peer-reviewed proceedings paper at(In the case of the sole author, underline is not required forinternational conferences or Peer-reviewed

the name of the degree applicant.)bulletin paper

Attach documents that can be judged by the mechanism of

the peer review system of the core papers.
Name, 〇〇, "title of the paper", international conference name, venue, date of conference, the beginning andthe end of pages of publication〇Taro Tsukuba and Hanako Tsuchiura,“A Frequency Domain Repetitive Control Algorithm for Robot
Manipulators”,Proc. of the 2nd Motion and Vibration Control Conf., Yokohama, Aug 2007, .12-20
Remarks: 1.When writing, be sure to refer to the "Degree Application Guide (Doctoral Program)."
2. In the case of a doctoral dissertation, the student ID number is not required.
3. The notation such as the volume or issue number, etc. of the paper should be subject to the notation of the offprints or its
copies.

).

Because the university will issue the diploma (both in Japanese andEnglish) based on the information of the full name field, please write it

Exampleclearly in block letters, and also fill in the spelling in English.

（別記様式－後予６）〔学位論文予備審査用〕

C u r r i c u l u m

V i t a e

A Shachihata seal is not acceptable.

Hiragana つくば
NameS e x

M/F(As of MM DD, 20XX)

Nationalityたろう

TSUKUBA Taro

Seal/Signature 筑波

TSUKUBA Taro
Date of Birth: MM DD, 19XX (Age: ○○)Entered on MM DD, YYYY
Education (higher than a university)

Graduated on MM DD, YYYY

Present Address 〒 305-8755
3-15-10 Kasuga, Tsukuba, Ibaraki
E-mail: tsukuba.taro＠gmail.com
Tel:090(8591)0001

Colleges of ○○, School of ○○, University of Tsukuba

Entered on MM DD, YYYY

Master’s Program in 〇〇,Completed on MM DD, YYYY

Graduate School of ○○, University of Tsukuba
Doctoral Program in Library, Information and Media Studies,Entered on MM DD, YYYY
Expected to complete on MM DD, YYYY

Graduate School of Library, Information and Media Studies,
University of Tsukuba

MM DD, YYYY
MM DD, YYYY
MM DD, YYYY
MM DD, YYYY
PeriodMM DD, YYYYtoMM DD, YYYY

MM DD, YYYYtoMM DD, YYYYMM DD, YYYYtoMM DD, YYYY

MM DD, YYYYtoMM DD, YYYY

MM DD, YYYYtoMM DD, YYYY

MM DD, YYYYtoMM DD, YYYY

MM DD, YYYYtoIbaraki

MM DD, YYYYWork experience, etc.
○○ Section, ○○ Division, ○○ Department, ○○ Corporation

If you have a work
experience, fill it out.

（別記様式－後予７）

ExampleMM DD, 20XX

To President of University of Tsukuba

春日A person who consented: KASUGA ○○Seal/Signature

Request the person who consented for
putting the name and the seal.

Letters of Consent

I agree that Mr. TSUKUBA Taro uses the results of the following papers in his dissertation.
In addition, this paper is not used as my degree dissertation, and it will not be used for my degree dissertation in thefuture either.

Name of dissertation:
Research on ○ ○ ○Name of published journal and publisher:
Journal of the Japan Society of Library and information
Volume, issue, page:Vol. 3, No. 5, pp. 111-150
Year of publication:
In 2016

Note: Be sure to obtain approval from all the authors.

（別記様式－後１３）

ExampleMM DD, YYYYTo Dean of Graduate School of Library, Information and Media Studies,

Non-plagiarized dissertation report

We checked the final version of the thesis using the plagiarism checking tool “iThenticate”.

ApplicantDoctoral Program in Library, Information and Media Studies
Student ID Number: 20XXXXXXX
N a m e: TSUKUBA Taro

筑波

(Signature or, Name and Seal)

Academic Advisor

A Shachihata seal is not acceptable.

Af f i l i a t i o n: Faculty of Library, Information and Media ScienceN a m e: KASUGA Hanako
春日(Signature or, Name and Seal)Exampleyyyy mm dd

To: Dean of the Graduate School of Library, Information and Media Studies
Ethics review report
The submitted doctoral dissertation underwent the necessary ethics review of its entries andwas confirmed to have approval as stated below.
1. Is something that is required by the ethics review found in the entries of the dissertation?
□ Yes□ No (For 2 and 3, no response needed.)

Place a check mark ✔ for appropriate
persons.

2. Write down the approval number, etc. with the implementing organization of the ethics
review where the approval was received.

Answer only if a check mark ✔was placed in “Yes” in 1.

Name of the Implementing Organization:
Approved number, etc.:

Write “Approved number” and “Approved date”

3. Confirm the following matters and place a check mark ✔.

Answer only if a check mark ✔wasplaced in “Yes” in 1.
□ The registration of all names as implementers, etc. in the ethics review related to thesubmitted dissertation by the person submitting the dissertation.

□ The date of approval of the ethics review is before the date of implementation ofinvestigations or experiments found in the entries of the dissertation.

□ There is no discrepancy between the entries of the dissertation and entries approved in theethics review. (It is unnecessary for all approved entries to be in the dissertation, however,investigations or experiments that should undergo ethics review other than the entries
approved must not be in the dissertation.)

Person submitting the doctoral dissertation
Doctoral Program in Library, Information and Media Studies, Graduate School of Library,
Information and Media Studies
Student Number: 20XXXXXXX
Name:Taro Tsukuba

Tsukuba(Signature or Name and Seal)

Faculty member in charge of research guidanceAffixing a self-inking stamp is not allowed.

Affiliation: Faculty of Library, Information and Media Science
Name: Hanako KasugaKasuga(Signature or Name and Seal)