Academic Certificates Request Form for Alumni
Faculty of Policy Management
Faculty of Environment and Information Studies
Graduate School of Media and GovernanceAcademic Affairs Office, Shonan Fujisawa Campus, Keio University5322 Endo, Fujisawa-shi, Kanagawa 252-0882, Japan
Email: sfcgakujireq@info.keio.ac.jp
Please send the following documents to the Academic Affairs Office, Shonan Fujisawa Campus, Keio
University:□ Request form (see second page of this document)□ A copy of alumni’s official identification
The University accepts only driver’s license, passport, health insurance card, the Certificate of
Alien Registration (copy of both sides) and Basic Resident Register card (with a photo).
Resident card, employee ID card and student ID card of other universities are not accepted.
□ Issuance fee
A money order (郵便定額小為替: yubin teigaku kokawase) or registered postal cash envelopeof total issuance fee. An alumnus/alumna who requests certificates from overseas and cannot
obtain yubin teigaku kogawase, he/she should enclose an international postal money order on
a Japanese yen basis.
□ Self-addressed stamped envelope or postage for EMSAll certificates are issued in A-4 size. Please enclose a large size self-addressed stamped
envelope when requesting sealed certificates or more than ten unsealed certificates.
An alumnus/alumna who requests certificates from overseas must enclose the postage for
EMS in Japanese stamps or international postal money order on a Japanese yen basis
instead of self-addressed stamped envelope.
In addition, an alumnus/alumna who wishes certificates to be mailed to an Attorney-in-Fact must submit thefollowing documents:□ Power of AttorneyMust be duly signed by the alumnus/alumna□ A copy of Attorney-in-Fact ’s official identification
The University accepts only driver’s license, passport, health insurance card, the Certificate ofAlien Registration (copy of both sides) and Basic Resident Register card (with a photo).
Resident card, employee ID card and student ID card of other universities are not accepted.
All inquiries concerning certificates for alumni should be addressed to the Academic Affairs Office, Shonan
Fujisawa Campus, Keio University.

Academic Certificates Request Form for Alumni
Academic Affairs Office, Shonan Fujisawa Campus,Keio UniversityYear/Month / Day

Date of Request/

FirstMiddle/

Name in Chinese characters and if there
is any Katakana
FamilyName in English

Year

Date of birth/Month /Day

GenderPresent mailing address(Please print clearly)
Zip code:
Email address
Daytime telephone number
Cell phone number

Student ID Number*If you do not remember, leave it blank.

Faculty of Policy Management
Faculty of Environment and Information Studies
Master’s Program,
Graduate School of Media and Governance

Month and year of
graduation/completion/withdrawal

78DoctoralProgram,
Graduate School of Media and Governance

8Issuance
fee percopy(JPY)

Name and Language of Certificate

Number of copies required
Undergraduate
ProgramCertificate of Graduation / Completion / Academic Degree Acquisition

Japanese□(Please tick the box)

Graduatedin2008orbefore□

Doctoral

Program

Program500

Transcript
AUD Shutoku Shomeisho

Master’s

Graduated in 2009 or after

1000
500

Certificate of Doctoral Candidate and Withdrawal
Certificate of Withdrawal

500

Others ()Certificate of Graduation / Completion / Academic Degree Acquisition

EnglishTranscript
Certificate of Doctoral Candidate and Withdrawal

500

Certificate of Withdrawal
Request Form for study abroad
Others ()Total amount (JPY):

Total number of copies:

Special request for sealed certificates
Please provide concrete instructions for sealed certificates. Certificates will not be sealed if no instructions are given here.