For Privately FundedInternational Students
私費外国人留学生用

Applicant Guidelines for 2024
Enrollment Fee Waiver and Deferment/
Tuition Waiver

2024 年度
入学料免除、授業料免除等の申請手続きについて

1

Contents

I. Enrollment Fee Waiver and Deferment Procedures................................p. ３
II. Tuition Waiver Procedures......................................................................p. ５
III. Submission of Application Forms..........................................................p. ６
IV. Instructions for Filling Out Applications...............................................p. ８2024 Application Period and Announcement Schedule◎Enrollment Fee Waiver and Enrollment Fee Deferment(Students enrolling in April)

From

to

2024 （Results announced in mid-May）(Students enrolling in October)

From

to

2024（Results announced in mid-November）◎Tuition Waiver（First Semester）○New students

From

to

2024

○Current students

From

to

2024

○New students

From

to

2024

○Current students

From 9/18 to 9/20 2024

(Results announced in late June)（Second Semester）(Results announced in late December)* If you cannot prepare all of the required documents to be submitted with the application form due tounavoidable circumstances, inform the office where your application is to be submitted ahead of timeand follow their instructions.
Applications that arrive after the deadline will not be accepted.

2*Please read before applying.
Government sponsored students and students on scholarships from anotherorganization, who are paying enrollment fee and tuitions but have been awarded ascholarship that provides the equivalent to that amount cannot apply for anenrollment fee or tuition waiver.

I. Enrollment Fee Waiver and Deferment Procedures
A. Eligibility for Enrollment Fee Waiver
Individuals to whom any one of the following applies:a) Individuals who will be enrolling in graduate school and find it difficult to pay
enrollment fees due to financial reasons and are recognized as having
outstanding academic ability.
b) The person responsible for paying the student's school expenses has died or the
student or the person responsible for paying his or her school expenses has
suffered damage from a storm, flood, or other natural disaster after April 1,
2023 (or October 1, 2023 if enrolling in October 2024).
c) There are reasons recognized by the University president as being equivalent
to the above (b).
d) The University president has recognized that special consideration isnecessary due to strong social needs.

B. Eligibility for Enrollment Fee Deferment

1. Students enrolling in graduate school (excluding research students and auditing
students)
Individuals who are recognized as having extreme difficulty in paying theenrollment fee, to whom any one of the following applies:a) Individuals who find it difficult to pay the enrollment fee by the deadline forpayment due to financial reasons and are recognized as having outstanding
academic ability.
b) Individuals who are recognized as having difficulty paying by the deadline dueto the death of the person responsible for paying their school expenses, or due
to damage suffered by them or the person responsible for paying their school
expenses from a storm, flood, or other natural disaster, occurring after April 1,
2023 (or October 1, 2023 if enrolling in October 2024).
c) Individuals recognized as having difficulty paying the fees by the deadline due
to other unavoidable circumstances.

3

C. Applying
Students applying for an enrollment fee waiver should apply for both enrollment
fee waiver and enrollment fee deferment when applying.
Individuals who apply for both enrollment fee waiver and enrollment fee
deferment but, as a result of the screening for enrollment fee waiver, are either notgranted a waiver or are granted a waiver for partial of the fee, will undergo ascreening for enrollment fee deferment. Those who pass that screening will be able
to postpone payment of the enrollment fee until the last day of August 2024 (or thelast day of January2025 if enrolling in October 2024).
D. Amount of Waiver
If the screening for the enrollment fee waiver results in the applicant being
granted a full or partial waiver of the enrollment fee, he or she will be exemptedfrom paying the full amount, or partial of the amount, of the normal enrollment
fee.
E. Notification of Screening Results
Applicants for enrollment fee waiver and enrollment fee deferment will be
notified of the results in Mid-May (or Mid-November if enrolling in October 2024).
The selection result will be notified by email to your Kyutech email address. Also,
please be aware that applicants who are not granted a tuition waiver or are
granted a partial waiver, and fail to pay the tuition by the due date designated by
the University will be disenrolled.

4II． Tuition Waiver Procedures
A. Eligibility for Tuition Waiver
Graduate students (excluding research students and auditing students) who arerecognized as having extreme difficulty in paying the tuition, to whom any one of
the following applies:
1. Individuals who find it difficult to pay the tuition due to financial reasons andare recognized as having outstanding academic ability.
2. Individuals who are recognized as having extreme difficulty paying the tuition
due to the death of the person responsible for paying their school expenses, ordue to damage suffered by them or the person responsible for paying their school
expenses from a storm, flood, or other natural disaster, occurring within six
months before the tuition deadline for that semester (or within one year if it istheir first semester at the University).
3. Reasons recognized by the University president as being equivalent to the above(2).
4. The University president has recognized that special consideration is necessary
due to strong social needs or some other reason.
* However, students currently enrolled who were unable to advance to the next year
or have exceeded their term of study (except due to special circumstances such as
illness or studying abroad) are not eligible to apply for a waiver even if any of theabove (1-4) applies.

B. Applying for Tuition Waiver
The application periods for tuition waivers differ for first and second semesters
and screening of applications is conducted separately for each semester.

C. Amount of Waiver
If the screening for tuition waiver results in the applicant being granted a full or
partial waiver of the tuition, he or she will be exempted from paying the full amount,or partial of the amount, of the normal tuition.

D. Notification of Screening Results
The result of the tuition exemption will be notified by email to your Kyutech
email address.
If you have to pay full tuition or half tuition,Kyutech will withdraw
automatically from your bank account on the specified date.
Please note that if you do not pay the tuition by the specified date, will resultin expulsion.
5III. Submission of Application Forms
A. Applying by Proxy (through your advisor or dean)
Applicants are permitted to have their academic advisor (or dean if an advisor has
not been decided on) apply on their behalf only if there are unavoidable
circumstances such as not being in Japan during the application period. Fill out therequired information on the application form in accordance with "IV. Instructions
for Filling Out Applications".

B. What to Submit (for all applications)
1. 2024 First Semester Enrollment Fee Waiver/ Enrollment Fee Deferment/
Tuition Waiver Application Form (for international students)
2. A copy of a part-time job pay slip, etc or A part-time job certificate (submit
only if you cannot submit a tax withholding slip or pay slip).
3. Scholarship Receipt Confirmation Form/Scholarship Receipt Certificate (forfirst year graduate students)*Only applicants entering graduate school at the University from anotheruniversity need to submit a Scholarship Receipt Certificate.
4. Copies of receipts for rent, utilities (water, electricity, gas) and phone (for 23 months)
5. Copy of your passbook or bank account statement (for about 6 months)
6. Sibling Enrollment and Tuition Waiver Status Certificate (submit only if
you have siblings who are students)

C. Where to Submit
Graduate School of Engineering:
School of Engineering Student Section
Phone: 093-884-3053（3054）
Graduate School of Computer Science and Systems Engineering:
School of Computer Science and Systems Engineering Student Section
Phone: 0948-29-7524
Graduate School of Life Science and Systems Engineering:
Graduate School of Life Science and Systems Engineering Student andInternational Student Section
Phone: 093-695-6007

6

D. Other Important Reminders
1. Incomplete or incorrectly filled out applications will result in your application
not being accepted. Be sure to submit application documents in plenty of time
before the deadline.
2. Once your application for enrollment fee or tuition waiver has been received,
you will be allowed to postpone the payment of such fees until you are notifiedof the results of the application screening. After applying, do not pay the fees
until the results of the screening are announced.
3. If it has been determined that false or misleading statements have been madein the application after the screening results have been announced, thewaiver/deferment may be revoked.

E. Handling of Personal Information
Information provided in the application form and other required documents
for enrollment fee and tuition waiver will be used only in the screening process
and not for any other purpose.

7IV． Instructions for Filling Out Applications
Application forms are an important part of the screening process, so be sure to readthis section carefully, and fill out the information based on your circumstances at thetime of the Application Base Date (April 1 for first semester, October 1 for second).
Applications that are incomplete, incorrectly filled out, or do not include all of therequired documentation will not be able to be processed and as a result will not be
considered for screening.
In addition, if it has been determined that information on the application form andother required documentation has been intentionally falsified after the screening
results have been announced, the waiver/deferment will be revoked.

A. Form 1: 2024 First Semester Enrollment Fee Waiver/ Enrollment Fee Deferment/
Tuition Waiver Application Form
Application Category
Place a check ☑ in the applicable boxes (Enrollment Fee Waiver/ Enrollment Fee
Deferment/ Tuition Waiver). If you are applying for an enrollment fee waiver, checkthe box for enrollment fee deferment as well.
If you are only applying for a tuition waiver, check the box for tuition waiver only.

Name and Academic Information
1. Write your full name and student status (e.g. school, department, year) in thespaces provided.
2. Currently enrolled students advancing to graduate school at this University
should write their old Student ID Number they used as an undergraduate.

Academic Advisor
Applicants are allowed to have their academic advisor (or dean if an advisor has
not been assigned) apply on their behalf only if there are unavoidable circumstancessuch as not being in Japan during the application period. The person filling out theapplication on the applicant's behalf must write the specific reasons why theapplicant is unable to apply his or herself, and sign and place his or her personalseal where indicated.
When the applicant arrives in Japan, he or she must fill out the other necessary
information and submit the required documents as soon as possible.

8

Reason for Applying
Describe your family circumstances and any other reason(s) that led you to apply.
Explain the reason(s) from your standpoint.

◎ Household Information Statement
Scholarships

Place a check ☑ in the "yes" box under "Receiving in 2023/2024?" if you havebeen awarded a scholarship or grant in the 2023/2024 academic year. If you are only
receiving a student loan, and not a scholarship or grant, place a check ☑ in the "no"box.
* If you check "yes", please indicate how long the scholarship or grant lasts and theamount awarded in the spaces provided.

Applicant/family members (except students) /roommate
1. Write your information in the space marked "① Applicant". In the spaces below(starting with ②), write the information of persons living with you in Japan (ifapplicable).
2. Under "Occupation", write the current job. If the person is not working, write
homemaker, unemployed, etc. Do not leave the space blank.
3. Under "Duration" write how many years the person has been working at his or
her current job (if under one year, write how many months).
4. The shaded area under "Income from wages" and "Income besides wages" will befilled out by the University. Do not write in this space.

Students Other than Applicant
Write the information for family members (not including yourself) who areenrolled in elementary, junior high, high school, college of technology, university(including graduate school), school for the deaf, blind, and disabled, or specialized
training college (upper secondary or postsecondary). Indicate where the person
commutes to school from, and whether the school is national, public, or private bychecking the appropriate boxes.
For family members enrolled in a national school (high school and above, notincluding yourself), check the appropriate boxes for details of waivers granted (ornot granted) in the previous academic year under "Waivers last year".
Unless you checked "none", write the amount of the regular tuition for one year
under "Waivers last year".

9◎ Official Use Only

Do not write in the shaded area.

◎ Average monthly income (including family income)

Make sure the totals for average monthly income and average monthly

expenditures are the same.

1. Part-time job: （Including TA • RA）
Write your income for one month earned from your part-time job. (If you areliving with other family members, including their income as well.)
2. Savings/remittance/financial aid:
Write the monthly total for money used from your savings to supplement living
expenses, remittance from your country, and/or financial aid received fromyour family.
3. Scholarships:
Write the amount received from scholarships or grants (do not include student
loans).
4. Child allowance/ child-rearing allowance:
Write the amount of child allowance received.
5. Other:If you have income from sources other than the above, write the amount in thespace provided.
6. Loans/deficit:
If you have any loans, or if the total for expenditures is greater than the total
for income, write the difference plus the total for loans in the space provided.
7. Total:Write your total income in the space provided.

◎ Average monthly expenditures (including family expenditures)* Calculate the average amount per month based on the copies of the receipts andpassbook or bank account statement you are submitting, and write the amount in
the space provided.
* If you have any family members enrolled in a university other than this university,
write the amount of their tuition in the space provided.
* If the total for income is greater than the total for expenditures, write thedifference in space marked "Surplus".

10◎ Income Statement

1. Write your income and the income of all family members (except students) in
the spaces provided.

2. For "Income from wages", write the amount including tax earned fromJanuary 2023 to December 2023.
* Make sure that when the total income is divided by twelve (one month's
income) the amount equals the income in "Average monthly income (including
family income)".
* If there are other sources of income that do fit into the categories provided,
write the source in the parenthesis and the amount in the space provided.
3. Round off all amounts to the nearest thousand.
4. Write the totals for income from wages and income from sources besides wages
for each person in the spaces provided.

B. Form 2: Part-time Job Certificate (Applicable person only)
Students currently working part-time must also submit a gensen-choshu-hyo(certificate of income and withholding tax) or payslip.
If you cannot submit a gensen-choshu-hyo (certificate of income and withholdingtax) or payslip, you must submit a Part-time Job Certificate signed by your employer.

C. Form 3: Scholarship Receipt Confirmation Form
Fill out the information for any scholarships or grants awarded to you in theprevious academic year (April 2023 to March 2024) and this academic year (April
2024 to March 2025).
* If you have been awarded a scholarship or grant that provides an amountequivalent to enrollment and/or tuitions (and which can only be used forenrollment and/or tuitions) while your application is being screened, be sure to
inform the University as soon as possible.
Do not write information for student loans that you are receiving, such as theJapan Student Services Organization Scholarship.

D. Form 4: Scholarship Receipt Certificate (for first year graduate students)
This form is for students enrolling in this University from another university inJapan. Submit this form after having it certified by your university.

E. Form 5: Sibling Enrollment Fee and Tuition Waiver Status Certificate
If you have any siblings who are students in Japan, fill out this form for eachsibling and have it certified by the school he or she is currently enrolled in, andsubmit it with your application. This does not apply to siblings who are in juniorhigh school or lower grades.
11様式－①※大学記入欄

受付日

令和6年

月

日

入学料

入学料徴収猶予

授業料

2024 Second Semester Enrollment Fee Waiver/ Enrollment Fee Deferment/Tuition Waiver
Application Form (for International Students) 令和6年度後期 授業料免除等申請書（留学生用）
Date of submission:
提出日 令和6年

Attention: President of Kyushu Institute of Technology
九州工業大学長 殿, 2024月日

I hereby apply for (□Enrollment Fee Waiver (入学料免除) □ Enrollment Fee Deferment （入学料徴収猶予） □Tuition Waiver（授業料免除）) for thereasons stated below. If any information on this application is found to be false or inaccurate, I will not raise any objections should thewaiver or permission to defer payment be withdrawn. I also consent to have my provided transcripts used for screening purposes. If I am
not granted a waiver or permission to defer payment, or am granted a waiver for half of the fee, I promise to pay the amount by the day
designated by the University.
下記の理由により、（ □入学料免除 □入学料徴収猶予 □授業料免除 ）を申請します。なお、申請内容に事実と相違があった場合は、免除または、徴収猶予の許可を取り消されても、異議はありません。また、選考にあたり、私の所定の成績を選考資料として使用されることに同意します。選考の結果、不許可もしくは半額免除となった際は、大学が指定する期日までに納付することを約束します。

Base Date: October 1, 2024/ 基準日 令和6年10月１日 現在
Year 学年
SchoolGraduate School
学部 / 学科 / 研究科

Student ID No. (leave blank if new)Former Student No. (if entering graduate school)

学生番号※新入生不要

学生番号※学内進学者

旧

Dept. Enrollment date 入学年月
学科 / 専攻

Name 氏名

E-mailMobile phone 携帯番号

Address 住所

Reason for applying(Must be written by applicant)（本人記入）
申請
理
由

Scholarship

Income Statement (for one year) ◎収入状況調書 （１年間の収入額を記入する）
Duration受給期間
Receiving in 2024
Receiving in 2023
給付
令和6年度受給令和5年度受給year
month - year month型（□yes有 □no無）（□yes有 □no無）
年
月
〜
年
月
奨
学 Name of scholarship 奨学金名金

Amount 受給額

Duration受給期間
year
month - year month
年
月 〜
年
月

Name of scholarship 奨学金名Amount 受給額,000 yen,000 yen

Income from wages 給与収入

Avg. monthly income (including family income) *round off to nearest thousand.

◎ １か月の平均収入（家族の収入も含む）(※千円未満切り捨て),000 yen,000 yen

Income besides wages 給与外収入

Avg. monthly expenditures (including family expenditures) *round off to nearest thousand.

◎ １か月の平均支出（家族の支出も含む）(※千円未満切り捨て)

Part-time job アルバイト,000 yen

Food 食費,000 yen

Savings/remittance/financial aid
預金・送金・援助金,000 yen

Rent 家賃,000 yen,000 yen,000 yen

Utilities and phone
水道光熱費・通信費Child allowance or Child-rearing allowance
児童手当・児童扶養手当等,000 yen

Tuition (not including applicant’s)
授業料 （本人の授業料は除く）,000 yen

Other その他（

,000 yen

Study and child-rearing costs
学習費・養育費,000 yen,000 yen

Other その他（

Total 合 計,000 yen

Surplus 余剰金

Extra-ordinary income 臨時的な所得,000 yen

Scholarships (monthly amount received last six
months) 奨学金 （直前の半期に受給した月額））

Loans/de cit 借入金・不足額,000 yen）,000 yen
Total 合 計,000 yen

Academic advisor(Reason applicant cannot fill out application him/herself) As soon as the applicant arrives in Japan, he/she will fill out the required information andsubmit the required documents. （本人が申請できない理由）なお、渡日後は速やかに本人が必要事項を記入及び必要書類を提出します。
指
導
教
員
等

Name of advisor 指導教員氏名㊞

Of cial use only. Do not write. ◎大学記入欄（何も記入しないでください。）

独立生計

☑

申請区分

□一般 ・ □特別学力基準

□入・□授（□可・□否）

修得単位

生活保護

□

収入基準

大学院（□前・□後）

学力基準

□猶予

成績評点

,000円

災害

世帯人数

人

障害者

人

長期療養

（□可・□否）,000円 入試成績(大学院)

１．Check the □ boxes that apply. □は、該当する項目に ☑ を記入してください。
２．Do not write in shaded areas, which are for of cal use only.
欄は大学で記入しますので記入しないでください。

単位Household Information Statement (round off to the nearest thousand) 家庭状況調書 （※千円未満切り捨て）（）

Family members

家
族

外

・
就
同
学
居
者
者
以

Relation
続柄

Age
年齢

Name

Occupation
職 業

氏 名

Duration
在職期間

Income from wages
給与収入

Income besides wages
給与外収入

①
②

Relation

続柄

Age
年齢

Name
氏名

Name of schoo
学校名l

Type
種別

Year
学年

Category
区分

Students other than applicant

本
人
以
外
の
就
学
者

Commute from
通学区分

□National国□Public公□Private私□home 自宅
□other 自宅外□National国□Public公□Private私□home 自宅
□other 自宅外□National国□Public公□Private私□home 自宅
□other 自宅外

Waivers last year (national schools only)
昨年度免除状況（国立学校のみ）
Yearly tuition
授業料年額First semester

Second semester

前期

後期□Ful l全免□Half 半免□Partial 一部□None 無□Ful l全免□Half 半免□Partial 一部□None 無,000 yen□Ful l全免□Half 半免□Partial 一部□None 無□Ful l全免□Half 半免□Partial 一部□None 無,000 yen□Ful l全免□Half 半免□Partial 一部□None 無□Ful l全免□Half 半免□Partial 一部□None 無,000 yen

Under “Type” write: (E) elementary, (J) Junior High, (H) High School, (U) University, (C) College of Technology, (SU)Specialized Training College upper secondary, or (PS) postsecondary. ※ 種別は小学校・中学校・高校・大学・高専・専高・専専から選択してください。
Income Statement (for one year) ◎収入状況調書 （１年間の収入額を記入する）
Relation 続柄
Applicant 本人
Category 区分

Income from wages

給
与
収
入

①

②

Part-time job （Including TA · RA）
アルバイト （ＴＡ・ＲＡを含む）,000 yen,000 yen,000 yenChild allowance or Child-rearing allowance
児童手当・児童扶養手当等,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen

Insurance bene ts保険金
Received(y)(m),000 yen,000 yen,000 yen(
Received,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen（）
Total wages 給与収入計

IncomeSavings/remittance/financial aid
預金・送金・援助金

収入状況Loans/de cit 借入金・不足額
Income besides wages

Scholarships 奨学金
給
与
外
収
入

（

）

Extraordinary
income
臨時的な所得(y))(m)

Total income besides wages
給与外収入計※大学記入欄 （臨時的所得チェック）

入

・

授

入

・

授

入

・

授

Special deductions ◎特別控除
Household with disabled person(s)障害者のいる世帯

Household struck by disaster
火災等の被災世帯
Household with someone requiring longterm care
長期療養者のいる世帯

Relation 続柄（） Registration no. 手帳番号（□Physical/mental disability, □requires care,□atomic bomb victim □心身障害 ・□要介護・□原爆被爆
Date of disaster 被災日 （Cost of damage 被災額 （Name of disaster 災害名 （Relation 続柄（Duration of care (治療期間 （
年

）

年

）

月）
yen）

Name of illness 病名（yearmonth 月） ～
年
月）

）
）
year

month)

様式－①

EXAMPLE / 記入例※大学記入欄

受付日

令和6年

月

日

入学料

入学料徴収猶予

授業料

2024 Second Semester Enrollment Fee Waiver/ Enrollment Fee Deferment/Tuition Waiver
Application Form (for International Students) 令和6年度後期 授業料免除等申請書（留学生用）
Date of submission: September 28 , 2024
提出日 令和6年 9 月 ２8

Attention: President of Kyushu Institute of Technology
九州工業大学長 殿日I hereby apply for (□Enrollment Fee Waiver (入学料免除) □ Enrollment Fee Deferment （入学料徴収猶予） □Tuition Waiver（授業料免除）) for
the reasons stated below. If any information on this application is found to be false or inaccurate, I will not raise any objections
should the waiver or permission to defer payment be withdrawn. I also consent to have my provided transcripts used for screening
purposes. If I am not granted a waiver or permission to defer payment, or am granted a waiver for half of the fee, I promise to pay theamount by the day designated by the University.
下記の理由により、（ □入学料免除 □入学料徴収猶予 □授業料免除 ）を申請します。なお、申請内容に事実と相違があった場合は、免除または、徴収猶予の許可を取り消されても、異議はありません。また、選考にあたり、私の所定の成績を選考資料として使用されることに同意します。選考の結果、不許可もしくは半額免除となった際は、大学が指定する期日までに納付することを約束します。

Base Date: October 1, 2024/ 基準日 令和6年10月１日 現在
SchoolCSSE Graduate School
学部 / 学科 / 研究科

Artificial Year 学年

1
Dept.
Intelligence 学科 / Enrollment date 入学年月
専攻
October 2024

Name 氏名
Dennis Bergkamp

E-mail×××―

Student ID No. (leave blank if new)Former Student No. (if entering graduate school)

学生番号※新入生不要

学生番号※学内進学者

246E1234

202C1234

旧Mobile phone 携帯番号
090-123-4567

1234＠☆☆☆☆

Address 住所

福岡県飯塚市川津680－4
Reason for applying(Must be written by applicant)（本人記入）
申 私は母国の●●大学で××の研究をしていました。研究を進める中で、九州工業大学でさらに知識を深めたいと思い留学を請理
由 決意しました。しかし、私の収入が少なく、母は病気で働くことができないため、毎月の仕送りだけでは生活ができません。

また、日本に来たばかりでアルバイトもしていません。是非とも、入学料免除と授業料免除をお願いします。

Scholarship

Income Statement (for one year) ◎収入状況調書 （１年間の収入額を記入する）
Duration受給期間
Receiving in 2024
Receiving in 2023
給
令和６年度受給令和５年度受給付
year
month - year month型（□yes有 no無）（□yes有 no無）
年
月
年
月
奨
学
金

Amount 受給額

Name of scholarship 奨学金名Duration受給期間
year
month
年
月

-

year
年

Amount 受給額

Name of scholarship 奨学金名,000 yen,000 yen

Income from wages 給与収入

month
月

,000 yen,000 yen

Income besides wages 給与外収入

Avg. monthly income (including family income) *round off to nearest thousand.

Avg. monthly expenditures (including family expenditures) *round off to nearest thousand.

◎ １か月の平均収入（家族の収入も含む）(※千円未満切り捨て)◎ １か月の平均支出（家族の支出も含む）(※千円未満切り捨て)

Part-time job アルバイト

40 ,000 yen

Food 食費

30 ,000 yen

Savings/remittance/financial aid
預金・送金・援助金

50 ,000 yen

Rent 家賃

30 ,000 yen
20 ,000 yen

Scholarships (monthly amount received last six
months) 奨学金 （直前の半期に受給した月額）,000 yen

Utilities and phone
水道光熱費・通信費Child allowance or Child-rearing
allowance 児童手当・児童扶養手当等,000 yen

Tuition (not including applicant’s)
授業料 （本人の授業料は除く）,000 yen

Study and child-rearing costs
学習費・養育費

Loans/de cit 借入金・不足額,000 yen

Other その他（

Total 合 計

90 ,000 yen

Other その他（）

Extra-ordinary income 臨時的な所得,000 yen

10 ,000 yen,000 yen）,000 yen

Surplus 余剰金,000 yen

90 ,000 yen

Total 合 計

Academic advisor(Reason applicant cannot fill out application him/herself) As soon as the applicant arrives in Japan, he/she will fill out the required information andsubmit the required documents. （本人が申請できない理由）なお、渡日後は速やかに本人が必要事項を記入及び必要書類を提出します。
指
導
教
員
等

Name of advisor 指導教員氏名

Of cial use only. Do not write. ◎大学記入欄（何も記入しないでください。）

独立生計
生活保護
世帯人数

□
人

申請区分

□一般 ・ □特別学力基準

□入・□授（□可・□否）

修得単位

収入基準

大学院（□前・□後）

学力基準

□猶予

成績評点

,000円

災害

障害者

人

長期療養

１．Check the □ boxes that apply. □は、該当する項目にを記入してください。

（□可・□否）,000円 入試成績(大学院)単位２．Do not write in shaded areas, which are for of cal use only.

欄は大学で記入しますので記入しないでください。

Household Information Statement (round off to the nearest thousand) 家庭状況調書 （※千円未満切り捨て）
家
族

（
）

Family members

外

・
就
同
学
居
者
者
以

Relation
続柄

Age
年齢

Name

Occupation
職 業

氏 名

Duration
在職期間

Income from wages
給与収入

Income besides wages
給与外収入

①
②

Relation

続柄

Age
年齢

Name
氏名

Name of schoo
学校名l

Type
種別

Year
学年

Category
区分

Students other than applicant

本
人
以
外
の
就
学
者

Waivers last year (national schools only)
昨年度免除状況（国立学校のみ）

Commutefrom
通学区分□National国□Public公□Private私□home 自宅
□other 自宅外□National国□Public公□Private私□home 自宅
□other 自宅外□National国□Public公□Private私□home 自宅
□other 自宅外

Yearly tuition
授業料年額First semester

Second semester

前期

後期□Ful l全免□Half 半免□Partial 一部□None 無□Ful l全免□Half 半免□Partial 一部□None 無,000 yen□Ful l全免□Half 半免□Partial 一部□None 無□Ful l全免□Half 半免□Partial 一部□None 無,000 yen□Ful l全免□Half 半免□Partial 一部□None 無□Ful l全免□Half 半免□Partial 一部□None 無,000 yen

Under “Type” write: (E) elementary, (J) Junior High, (H) High School, (U) University, (C) College of Technology, (SU)Specialized Training College upper secondary, or (PS) postsecondary. ※ 種別は小学校・中学校・高校・大学・高専・専高・専専から選択してください。
Income Statement (for one year) ◎収入状況調書 （１年間の収入額を記入する）
Relation 続柄
Applicant 本人
Category 区分
480②,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen

480,000 yen,000 yen,000 yen

600,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen

Insurance bene ts保険金
Received(y)(m),000 yen,000 yen,000 yen(
Received,000 yen,000 yen,000 yen,000 yen,000 yen,000 yen

Part-time job （Including TA RA）
アルバイト （ＴＡ・ＲＡを含む）
Income from wages

給
与
収
入

①

Child allowance or Child-rearing allowance
児童手当・児童扶養手当等（）
Total wages 給与収入計

IncomeSavings/remittance/financial aid
預金・送金・援助金

収入状況Loans/de cit 借入金・不足額
Income besides wages

Scholarships 奨学金
給
与
外
収
入

（

）

Extraordinary
income
臨時的な所得(y)Total income besides wages
給与外収入計※大学記入欄 （臨時的所得チェック）

)
(m)
600

入

・

授

入

・

授

入

・

授

Special deductions ◎特別控除
Household with disabled person(s)障害者のいる世帯

Household struck by disaster
火災等の被災世帯
Household with someone requiring longterm care
長期療養者のいる世帯

Relation 続柄（） Registration no. 手帳番号（□Physical/mental disability, □requires care,□atomic bomb victim □心身障害 ・□要介護・□原爆被爆
Date of disaster 被災日 （Cost of damage 被災額 （Name of disaster 災害名 （Relation 続柄（Duration of care (治療期間 （
年

）

年

）

月）
yen）

Name of illness 病名（yearmonth 月） ～
年
月）

）
）
year

month)

様式―②

アルバイト証明書（該当者のみ）
Part-time Job Certificate (Applicable person only)
学生番号 Student ID No.
氏名 Name☑を付してください。* Check the boxes that apply.

※該当する項目に

この度、九州工業大学に（□入学料免除・□入学料徴収猶予・□授業料免除）の申請を行いますので、下記事項について証明願います。

I am applying for ( □ enrollment fee waiver （ 入 学 料 免 除 ） , □ enrollment fee
deferment（ 入学料徴収猶予 ）, □ tuition waiver （ 授業料免除 ）) at Kyushu Institute ofTechnology, and hereby request certification of the matters described below.
記
業務内容
Job duties
雇用期間
Duration of employment

年

From (yyyy/mm):

月から現在に至る

to present

１ケ月当たりの支払い金額

円（平均）

Average monthly wages

yen (average)

上記のとおり、相違ないことを証明します。

I hereby certify that the above is true and correct.
年

月日

Date (yyyy/mm/dd):【証明者】Certified by

会社名等 / Name of company or organization

氏名 / Name㊞

様式―③

Scholarship Receipt Confirmation Form 奨学金受給確認書
Student ID No. 学生番号
Name 氏名☑

* Check the boxes that apply. ※該当する項目にを付してください。
I, (name:), the (□applicant（本人）□husband of applicant（夫）□wife of applicant （妻）)for (□tuition waiver（授業料免除）, □enrollment fee waiver（入学料免除）, □enrollment fee deferment（入学料徴収猶予）), hereby declare my scholarship/grant status to be as follows.
（□授業料免除 ・ □入学料免除 ・ □入学料徴収猶予 ）申請にあたり（□本人・□夫・□妻）氏名の給付型の奨学金受給状況は下記のとおりです。
1. Scholarships for the previous academic year (April of last year to March of this year).
昨年度（昨年４月～今年３月）の奨学金について□I did not receive any scholarships or grants. 奨学金を受給していない□I received the following scholarship(s) or grant(s). 次のとおり奨学金を受給していた
Name of Scholarship

Duration of Scholarship

Monthly Amount

Total Amount

奨学金名称(yyyy/mm) 受給期間

受給月額

受給総額

From:

/

to

/

yen

yen

From:

/

to

/

yen

yen

Total 合計:
(April of this year to March of next year).

2. Scholarships for this academic yearyen

今年度（今年４月～来年３月）の奨学金について□I am not receiving any scholarships or grants.
奨学金を受給していない□I am receiving the following scholarship(s) or grant(s). 次のとおり奨学金を受給する（予定である）
Name of Scholarship
奨学金名称

Duration of Scholarship(yyyy/mm)

Monthly Amount

Total Amount

受給月額

受給総額

受給期間

From:

/

to

/

yen

yen

From:

/

to

/

yen

yen

Total 合計:yen

3. Scholarships I am (or my spouse is) currently applying for.
現在申請中の奨学金について* If you are currently applying for a scholarship/grant that provides an amount equivalent to enrollment
and/or tuitions (and which can only be used for enrollment and/or tuition fees), please fill out the
information below.
※ 現在、入学料相当額または授業料相当額を支給する（入学料または授業料に使途が限定された）奨学金に申請中の方は、以下に記入してください。

Name of Scholarship

Duration of Scholarship

Type 支給対象

Total Amount

奨学金名称(yyyy/mm) 受給期間

Circle all that apply

受給総額

From:

/

to

/

From:

/

to

/

Enrollment 入学料
Tuition 授業料
Enrollment 入学料
Tuition 授業料

yen
yen

* If you are accepted to receive a scholarship or grant that provides an amount equivalent to enrollment
and/or tuitions while your application is being reviewed, your application may be withdrawn. ※ 入
学料相当額または授業料相当額の給付奨学金の受給が決まった場合、申請受理後であっても申請を取り消すことがあります。

* Only scholarships and grants are factored in as income. Student loans, such as the Japan Student
Services Organization Scholarship, do not need to be reported.
※ 奨学金は給付型の奨学金のみ収入として算入します。日本学生支援機構奨学金等 貸与型のものについては、申告不用です。

様式―④

奨学金受給証明書（大学院１年次生用）
Scholarship Receipt Certificate (for first year graduate students)
奨学事務担当者 殿
Attention: Scholarship Office
卒業・修了年月年月

Graduation date
学生番号 Student ID No.

Year

Month

氏名 Name※該当する項目に☑を付してください。* Check the boxes that apply.

この度、九州工業大学に（ □入学料免除 ・ □入学料徴収猶予 ・ □授業料免除 ）の申請を行いますので下記事項について証明願います。

I am applying for (□enrollment fee waiver（入学料免除）, □enrollment fee deferment（入学料徴収猶予）,□tuition waiver（授業料免除）) at Kyushu Institute of Technology, and hereby request certification of
the matters described below.
１.昨年度奨学金受給状況について Scholarships received in the previous academic year.

□受給なし I did not receive a scholarship or grant.
□受給していた（下記の欄にも記入願います）
I received the following scholarship/grant (please fill out the information below).
給付型奨学金[ 名称 ：Name of Scholarship[Name ：]

受給期間 ：

年

月

Duration

year

month

２.現在申請中の奨学金について

]
～

年

year

月

month

月額 ：

Amount/month:円

yen

Scholarships you are currently applying for.

※ 奨学金使途記入欄には、入学料相当額や授業料相当額の奨学金が受給される等の場合で奨学金の使途が定められているものを記入してください。

If you are applying for a scholarship/grant that provides an amount equivalent to enrollment and/or
tuitions, write the specified use of the scholarship by "Use of Scholarship".

□申請していない I am not currently applying for a scholarship or grant.
□次の通り申請している（下記の欄にも記入願います）
I am applying for the following scholarship/grant (please fill out the information below):
給付型奨学金[ 名称 ：Name of Scholarship[Name ：]]

奨学金使途：

Use of Scholarship:
受給期間 ：

年

Duration

year

月

month

～

年

year

月

month

月額 ：

円

Amount/month:yen

上記のとおり証明します。

I hereby certify that the above is true and correct.
年

月

Year

Month

日

Day

学校名
Name of School
証明者の職名・氏名

Name and title of certifier㊞※ 本書類は日本国内の他大学から九州工業大学大学院に入学する学生のものです。

※ This form is for students entering graduate school at Kyushu Institute of Technology from anotheruniversity in Japan.
※ 本学学部生が進学するに当たり書類を提出する際には、奨学金受給確認書を使用してください。

※ Undergraduate students currently enrolled at Kyushu Institute of Technology advancing to graduate
school should submit a Scholarship Receipt Confirmation Form instead.

様式―⑤兄弟姉妹等の在学状況及び授業料免除状況証明書

Sibling Enrollment and Tuition Wavier Status Certificate
各 学 校 等 事 務 担 当 者 殿

Attention: School Administration Office【証明を受ける者】(授業料免除申請者の兄弟姉妹等)

Sibling of applicant for tuition waiver

学生番号 Student ID No.
氏名 Name※該当する事項に「☑」を付してください。* Check the boxes that apply.
この度、九州工業大学に在学中の私の兄弟姉妹等 学生番号：

氏名が、□入学料免除・□入学料徴収猶予・□授業料免除申請するため、私の下記事項について証明願います。
I, the sibling of the undersigned, who is currently enrolled at Kyushu Institute of Technology and applying for (□ enrollment fee
waiver （入学料免除）, □ enrollment fee deferment （入学料徴収猶予）, □ tuition waiver （授業料免除申請）), hereby request certificationof the following matters regarding my academic and scholarship status.
Student ID No.

Name:

１．在学状況 （2024 年４月１日以降） Enrollment Status (from April 2024)
年度入学（※年度を記入してください。
）Year of enrollment (indicate the academic year)

入学年度： 平成・令和

通学区分 Commute：□自宅 From home
□自宅外 Other
設置区分 Category：□国立 National□公立 Public □私立 Private
学校区分Type of School： □大学，大学院，短大University/junior college□高等専門学校College of technology □高等学校High school□専修学校（専門課程）Specialized training college (postsecondary)□専修学校（高等課程）Specialized training college (upper secondary)□専修学校（一般課程）Specialized training college (general)□各種学校 Special Institutes□その他 Other（）

2．2023 年度授業料免除状況について（国立大学法人又は独立行政法人の学校に在学する学生のみ記入）

2023 Tuition Waiver Status (only fill out if enrolled in a national university corporation or independent administrative institution
school)□2024 年度入学の為、該当ありません。Not applicable because he/she will enroll in the 2024 academic year

Yearly amount of tuition

前年度の授業料免除実施状況

Tuition waiver status for the previous year
前期First semester

後期
Second semester

授

業

yen
料

年

額

Total amount of waiveryen

円□全額免除 □半額免除 □一部免除
□不許可
□申請無
□Full waiver □Half waiver □Partial waiver □No waiver □Did not apply□全額免除 □半額免除 □一部免除
□不許可
□申請無
□Full waiver □Half waiver □Partial waiver □No waiver □Did not apply

免除額
免除額

Total amount of waiver

円
円

yen

（貴学を卒業・終了した者が引き続き大学院に入学・進学した場合は，前年度の状況について証明願います。）(If the student has received an undergraduate degree at your school and is advancing to graduate school, please
certify his or her status for the previous academic year.)
上記のとおり、相違ないことを証明します。

I hereby certify that the above is true and correct.
年

月日

Date (yyyy/mm/dd):
学校名 / Name of school:
証明者の職名・氏名 / Name and occupation of certifier：※ 貴学の新入生の場合は，入学後に証明をお願いします。

* If the student will be newly enrolled at your school, please certify the information after he or she enrolls.

㊞