St. Luke's International University
Request Form for Certificates
聖路加国際大学 証明書申込書
Date:

/記入日

Year of Admission
入学年（西暦）Year:

Affiliation/YearMonthDay☐ College of Nursing (看護学部)☐ Graduate School of Nursing Science(看護学研究科)☐ Graduate of School of Public Health(公衆衛生学研究科)

Student ID No.
学籍番号Student Name
在籍時の氏名*As written on your student ID card during your enrollment

Date of Birth
生年月日
Phone No.
電話番号/

Year()-Month/Day

Email
メールアドレス@*All personal information provided here shall only be used for issuing certificates.
本申込書にご記入いただいた個人情報は、証明書の作成上の必要事項としてのみ利用します。

1. Choose the certificate(s) you would like to order. 申込証明書の種類
Check Type of Certificate
証明書の種類Certificate of Enrollment☐
在学証明書
Certificate of Expected Graduation☐
修了見込証明書Certificate of Graduation☐
修了証明書
Transcript (1,000 yen fee is charged for English transcripts)☐
成績証明書（英文成績証明書は 1,000 円）
Letter of Recommendation 推薦書☐(Thesis supervisor 論文指導教員:)☐

Other その他 (Japanese (和文)¥500/per copy
通copies通
copies通
copies通
copies通
copies通
copies通copies)Issuance Fee 発行手数料

English (英文)¥700/per copy

(1,000 yen)

通copies通copies

通copies

通copies

通copies

YenYen2. Purpose of Use 証明書の使用目的
3. Would you like the certificate in a sealed envelope? 証明書の厳封: ☐ Yes 必要
4. Method of receipt 受け取り方法: ☐ At the university counter 窓口☐ No 不要☐ Postal mail 郵送(Postage 郵送料:)------------------------------------------- (If applying by postal mail) 【郵送申込の場合】------------------------------------------------Please enclose the following with your application. 同封物をご確認ください☐ Certificate Fee(s) 証明書料金☐ Self-addressed stamped envelope 返信用封筒（切手貼付）☐ A copy of your ID 本人確認書類

SampleSt. Luke's International University
Request Form for Certificates
聖路加国際大学 証明書申込書

Year of Admission
入学年（西暦）Year:

Student ID No.
学籍番号24MP000

Student Name
在籍時の氏名Affiliation

2024

記入日

Year/04/

Month01Day☐ College of Nursing (看護学部)☐ Graduate School of Nursing Science(看護学研究科)☒ Graduate of School of Public Health(公衆衛生学研究科)*As written on your student ID card during your enrollment

SEIRUKA CHRISTOPHER

Date of Birth
生年月日
Phone No.
電話番号

2024

Date:Year
1989(080 ) 1111/- 0000

Month10/

Day04

Email
メールアドレス

24mp000@ slcn.ac.jp*All personal information provided here shall only be used for issuing certificates.
本申込書にご記入いただいた個人情報は、証明書の作成上の必要事項としてのみ利用します。

1. Choose the certificate(s) you would like to order. 申込証明書の種類
Check Type of Certificate
証明書の種類Certificate of Enrollment☒
在学証明書
Certificate of Expected Graduation Date☐
修了見込証明書Certificate of Graduation☐
修了証明書
Transcript (1,000 yen fee is charged for English transcripts)☒
成績証明書（英文成績証明書は 1,000 円）
Letter of Recommendation 推薦書☐(Thesis supervisor 論文指導教員:)☐

Other その他 (Japanese (和文)¥500/per copy

1通copies

通copies

通copies

通copies

通copies

通copies

通copies)Issuance Fee 発行手数料

English (英文)¥700/per copy

500

1

通copies

通copies

通copies

通copies

通copies

Yen

1,000

Yen

2. Purpose of Use 証明書の使用目的

Visa extension application
3. Would you like the certificate in a sealed envelope? 証明書の厳封: ☐ Yes 必要
4. Method of receipt 受け取り方法: ☒ At the university counter 窓口☒ No 不要☐ Postal mail 郵送(Postage 郵送料:)------------------------------------------- (If applying by postal mail) 【郵送申込の場合】------------------------------------------------Please enclose the following with your application. 同封物をご確認ください☐ Certificate Fee(s) 証明書料金☐ Self-addressed stamped envelope 返信用封筒（切手貼付）☐ A copy of your ID 本人確認書類