Application NO.:

office use only

Application Form for Students with Scholarship by the China Scholarship Council
Degree Programs in Systems and Information Engineering,
University of Tsukuba
INSTRUCTIONS
1. The application should be typewritten, or neatly handwritten in block letters.
2. Numbers should be in Arabic numerals.
3. Dates should be written in Western calender.
4. Proper names should not be abbreviated.
* Personal data provided in this application will only be used for affairs concerning selection, admission and scholarship selection purposes, andcontact information such as e-mail addresses will only be used for forming related human networks after the student returns home and forsending of information by the University of Tsukuba(Sex)
1. Name in fullin the language of your country(Family name)

In Roman block capitals(Family name)□Male，(First name)(Middle name)(First name)(Middle name)□Female(Marital Status)，□Single□Married

In Japanese, if possible withfurigana,(Family name)(First name)(Middle name)

2. Nationality

Photograph(4cm×3cm)

3. Date of birth
YearMonthDay

Age (as of January 1, 2021)

4. Your present status with the name of the university to which you are attendingYour upper body,without headgear,taken within the past
three months.

5. Applicant’s contact information

Present address：
Telephone number：
E-mail address：* If possible, write an e-mail address that can be used (1) before your coming to Japan, (2) while staying in Japan, and (3) after returninghome.
6. Field of specialization studied in the past (State as detailed and specific as possible.)* You may use an additional sheet ifneeded.

Application NO.:

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7. Desired doctoral program at the University of Tsukuba
Doctoral Program:
Name of prospective supervisor:
8. Are you applying to other universities? If so, which university?

9. Educational background

Year and Monthof Entrance andCompletion

Name and Address of School(Number of yearsattended)

Name
Elementary Education
Location(Name
Secondary Education
Lower Secondary School

Location(Location(Name
Higher Education
Undergraduate Level

FromToLocationName(FromTo

Graduate Level
Location

Total years of schooling mentioned above

Mth,

Yr,

Mth,yrsyrs)

Yr,Mth,Yr,Mth,yrsyrs)

FromToUpper Secondary SchoolYr,

FromToNameDiploma or Degree awarded,
Major subject

FromToElementary School

Officially required
number ofyears ofschooling(Yr,Mth,Yr,Mth,yrsyrs)

Yr,Mth,Yr,Mth,yrsyrs)

Yr,Mth,Yr,Mth,yrsyrs)

yrs

yrs

* If the blank spaces above are not enough to fill in the required information, you may use an additional sheet and attach it to this form．

Application NO.:

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10. List of publications (books or papers including your Master’s thesis). You may use an additional sheet if needed. Attach abstracts to the list ofpublications.

11. Employment Record: Begin with the most recent employment, if applicable.
Name and address of organization

Period of employment

Position

Type of work

FromToFromTo12. Japanese language proficiency: Evaluate your level and insert an X where appropriate in the following blank space.
Excellent

Good

Fair

Poor

Reading
Writing
Speaking

13. Have you been awarded a Japanese Government (MEXT) Scholarship in the past? If so, please specify the period and the name of theuniversity you stayed.
i) Yes, I have.
Period:University name:ii) No, I have not.
14. Is there anyone in your family who has been awarded or is applying for a Japanese Government (MEXT) Scholarship? If yes, give his/hername here.
Name:
Relationship with the applicant:(Awarded / Applying)Application NO.:

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15. Person to be notified in applicant's home country in case of emergency:i) Name in full:ii) Contact information

Present address：
Telephone number：
E-mail address：iii) Occupation:iv) Relationship with the applicant:Date of application:
Applicant's signature:

Applicant's name（in Roman block capitals）：

以下

本学記入欄

出願資格
設

置

国立

公立

私立

外国

その他

（該当するものを○で囲む）

大学名（大学院）
研究群名
学位プログラム名

資

格

修了見込

修了

その他

修了（見込）年月

年（該当するものを○で囲む）
月