International University of Japan
Intensive English Program for Summer Only Students
国際大学夏期英語集中講座（IEP）申込書
必要事項をご記入の上、添付書類（（１）２年以内に受験した TOEIC スコアシートの写し、（２）顔写真データ）を添えてiep@iuj.ac.jpまでメール添付でお送り下さい。受講申込書は和文と英文に分かれていますが、両方にご記入下さい。
問合せ先： 949-7277 新潟県南魚沼市国際町777 国際大学 IEP担当
電話：025-779-1498 E-mail：iep@iuj.ac.jp
記入日：年月

顔写真日

受講者
ふりがな

生年月日
（西暦）

氏名

年令
□自宅
〒

□勤務先

年才

月

性別

電話

連絡先

FAX
E-mail
企業・機関：
所属部課・役職：

勤務先企業・機関

所在地：〒

Email：

電話：

現在担当業務

受講料等
経費負担

１．本人

２．企業・機関

３．その他

派遣元企業・機関
企業・機関名〒所在地部署・役職名
ふりがな

電話

ご担当者名

E-mail緊急時連絡先
氏名

受講者との関係

電話※ご記入いただいた情報は、カリキュラム開発・案内書送付等、本プログラム実施にかかわる諸業務のためにのみ使用いたします。
1日International University of Japan

Intensive English Program for Summer-only Students
Application Form
Please fill in this form and send it back by email to < iep@iuj.ac.jp >Contact information:

Office of Academic Affairs, International University of Japan
777 Kokusai-cho, Minami Uonuma-shi, Niigata-ken, 949-7277 Japan
Phone: +81-25-779-1498 FAX：+81-25-779-1187 E-mail: iep@iuj.ac.jp
Gender:Date of Birth:

Applicant’s Name
(Last name, First name)□ Home □ Work〒

Applicant’s Contact
Address
Phone:
Fax:
E-mail:Name of Company/Organization:
Current Position:
Your Specific Responsibilities within the Office: (in detail)Name:
Title:
Contact Personat Sponsoring
Organization(If you have filled in theJapanese form, you may
disregard this section.)

Address:

Phone:
Fax:
E-mail:2Female/dd

Age:Applicant’s Current
StatusMale /years/mmyyyyEducational Background:
Undergraduate and graduatelevel.

University/School Name

Major/Dept.

Degree Title

Date Earned1.

Please provide info on all your 2.
academic background ofundergraduate level and3.
above.
Have you attended any English conversation schools or English programs?
□ Yes□ No
Name of school & location (city and/or country):
English Schools

Purposes:
Year & duration including how many hours of instruction per week:

English Tests Taken

TOEFL scores:

Year & Month Taken:

TOEIC scores:

Year & Month Taken:

IELTS:

Year and Month Taken:

Others:Overseas Experiences
including work, exchange
program, tour, etc. Please
include name of the country,
school and duration.

Please assess your English
communication skills (pleasecircle the most appropriate)

ReadingStrong

Good

Average

Poor

Writing

StrongGood

Average

Poor

Speaking

StrongGood

Average

Poor

Listening

StrongGood

Average

Poor

Conversation

StrongGood

AveragePoor:

fluentfair

survival level:

fluentfairsurvival level:

fluentfair

survival level

Skills you would like toimprove in IEP
1.
Knowledge of languages otherthan English and your mother 2.
language. Please circle yourproficiency levels as well.
3.
Interests (cultural & sports)
During IEP I plan to live in a/an□ single student dormitory (SD1) □ off-campus apartment.
* Information provided will only be used for the operation of the program including curriculum development,sending announcements, better assisting you and so forth.
3

英文エッセイについて下に示すテーマについて、説明にしたがってA4、単語数300～350語以内で英文のエッセイを書いてください。これは、おおよその英語ライティング力を見るためのものですので、辞書は使用可ですが、誰かに相談したりせず、自分の力で書いて下さい。
“In what areas will IUJ‘s summer Intensive English Program help you to develop yourcareer? Do not discuss more than three areas.”
The essay should be 300-350 words. Use a computer to write the essay. It should be
double-spaced, 12-point font size. Use "Times New Roman" as font. You must write theessay on your own. Do not ask someone else to edit or proofread the essay. You may use adictionary.

4