School of Medicine First Round of Special Entrance Examinations forReturnee Students ＆ Students of International School Application Form
Prior confirmation＊Please select your qualification for applying to the Special Entrance Examinations for Returnee Students& Students of International School among below (1) ~ (5).
※Multiple answers allowed☐⑴ Applicants must have studied more than four academic years, including the final school year(It does not have to be fouryears of continuous study), out of a 12-year school program and graduated from an overseas school (including those whoare expected to complete it by March 31st, 2025), or have studied more than four academic years, including the final schoolyear(It does not have to be four years of continuous study), and graduated from an overseas Japanese school (including
those who are expected to complete it by March 31st, 2025), which is classified as its overseas educational institution by theMinistry of Education, Culture, Sports, Science and Technology (MEXT).

☐ ⑵ Applicants must have spent more than 2 years and graduated from a university or college and postgraduate
course outside Japan (including those who are expected to complete them by March 31st, 2025).
☐ ⑶ Applicants must have spent more than 6 years outside Japan since they turned 6 years of age.
☐ ⑷ Applicants must have spent more than 2 years (including the final school year) and graduated from an international
school in Japan (including those who are expected to complete them by March 31st, 2025).

□ (5)Applicants must have received or expect to have received the International Baccalaureate Diploma (IB Full Diploma)
from the International Baccalaureate Organization, a foundation based on the Swiss Civil Code, and must havecompleted the courses specified by our university and meet the grade requirements.

1 Applicant information
Family name

Namein Englishin katakana

First name, Middle nameex)Daigakuex)Taroex)ダイガクex)タロウGender☐ Male☐ Female

Date of birth (yyyy/mm/dd)ex)1999/4/16

Nationalityex)JapanStreet number
CityState・Prefecture
Country・Region
Phone number
Mobile phone
E-mail address

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2. Resume＊Please fill in your academic history (including Japanese language school) and work experience (including unemployed history andperiod of military obligation) since the entrance of the elementary school.
＊Applicants who were already graduated from high school are required to write down their academic and employment history such as
preparatory school for university (including the name of the school building), home schooling, attendance of other university andunemployment period so that there will be no blank period.
＊For each history, please clearly describe its circumstance such as “expected graduation”, “graduation”, “transfer”, “transferredadmission”, “dropout”, and “retirement”.

From(yyyy/mm)

To(yyyy/mm)

Academic History ＆ Working Experience

2018/092021/06〇〇 high school. “Graduated. ”

3-1 Information of guardian
Last name
Relationship with Applicant

First name, Middle nameex)Father

Street number
City
State・Prefecture
Country・Region
Phone number

p. 23-2 Information of defrayer for tuition fees and living expenses
Last name

Relationship with Applicant

First name, Middle nameex)Father

Street number
City
State・Prefecture
Country・Region
Phone number

4-1 National Qualification
Title of the qualification

Date of Acquisition(Month/Year)Country・Region where you acquired

2017/06

United States of America

PT（National Physical Therapy Exam）

4-2 About submitting score (only applicants who wish to submit)＊“Examination for Japanese University Admission for International Students (EJU)”(Only results of sessions conducted in June 2022 or afterwards
will
be reviewed
for admission purposes regardless ofSession
which subjects
and languages (Firstwereorselected.)
Dateof Examination(Month/Year)of ExaminationSecond)

Examinee Registration Number＊Official test scores of TOEFL or IELTS

Name ofAwarding Institution

Date of Acquisition(Month/Year)

Test TypeTOEFL

IBTIELTS-ScoreReference Number ofOfficial Transcript
Registration number
TRF number＊Last question
Criminal record (in Japan / overseas)

☐ Yes

☐ No

Departure by deportation / departure order☐ Yes☐ NoIf yes, details☐ There is no fabrication I made above.
Please make sure to check again whether you fill in every section of this application form carefully and completely.
Please send this form together your application materials vie e-mail as attachments at a same time.
Thank you for your cooperation.

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