School of Medicine First Round Special Entrance Examinations
for International Students Application Form
Prior confirmation
Applicants must meet all the following requirements.
(1)Applicants must have neither Japanese nationality nor permanent residential status in Japan.
(2)Applicants must either have completed 12 years of school education outside Japan (including those whoare expected to complete them by March 31st, 2025), or meet equivalent conditions specified above anddesignated by the Ministry of Education, Culture, Sports, Science and Technology (MEXT).
(3)Applicants must be able to obtain the “Student (Ryugaku)” visa mandated by Japanese Immigration
Control and Refugee Recognition Act by the time of enrollment.
(4)Applicants must have an adequate English proficiency to attend lectures in that language.
※ As a reference guideline, it is preferable to have either at least 80 of TOEFL iBT score or 6.0 of IELTS
score.

【Select the language for the first phase screening (written examinations)】☐ Japanese☐ English【Select the language for the second phase screening (individual interviews)】☐ Japanese☐ English

1 Applicant information
Namein Englishin katakana

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

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

Street number
CityState・Prefecture
Country・Region
Phone number
Mobile phone
E-mail address
p. 1

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 suchas 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)FatherStreet number
City
State・Prefecture
Country・Region
Phone numberp. 23-2 Information of defrayer for tuition fees and living expenses
Family name

Relationship with Applicant

First name, Middle nameex)FatherStreet numberCity
State・Prefecture
Country・Region
Phone number

4-1 National Qualification(only holders)
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 subjectsand languages wereDateof Examination(Month/Year)of Examination(First selected.)or Second)

Examinee Registration Number＊Official test scores of TOEFL or IELTS

Name ofAwarding Institution

Date of Acquisition(Month/Year)

Test TypeTOEFL

IBTIELTS-Reference Number ofScore

Official Transcript
Registration number
TRF number＊Last question
Criminal record (in Japan / overseas)

☐ Yes

☐ No

Departure by deportation / departure order

☐ Yes

☐ No

If 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.

p. 3