FOR OFFICIAL USE

Application No:
Please paste a photo facingstraight at the camera
and taken within 3 months

APPLICATION FOR ADMISSION/TRANSFER
TO THE ENGLISH ENGINEERING EDUCATION PROGRAM (e3)
GRADUATE SCHOOL OF ENGINEERING
HOKKAIDO UNIVERSITY(for those who already passed the entrance exam/ current
students of Graduate School of Engineering)☐ MASTER’S PROGRAM☐ DOCTORAL PROGRAM
Desired enrolment:☐ April 20☐ October 20☐Male☐Single

I apply for e3 financial incentive for Japanese students ☐☐Female☐MarriedI apply for free English examination support for Japanese students ☐INSTRUCTIONS:▪ Please type in the application. If handwriting, please write neatly in capital blockletters.
▪ Attach all the necessary documents specified in the list of application documents.
▪ Unclear or incomplete application without proper explanation will not be considered.

(1) Name (in Roman letters)

Surname/Family nameFirst name(2) Nationality

Middle name(3) Date of Birth (DD/MM/YYYY)(4) Current Address
Zip code:

Address:Phone

E-mailAll the announcements will be sent by e-mail. Please make sure to provide a correct and valid e-mail address which
can be used for the whole period of your application.

(5) Permanent Address
Zip code:

Address:Phone

E-mail(6) Supervisor
Professor’s nameName of the Laboratory
Laboratory ofDivision(7) The Title of Research Proposal
Please write down the title of your planned research and attach a research proposal (in details if you are applying fora doctoral program).
(i)(8) Educational BackgroundYou shall prepare official academic transcripts (complete or the most recent by the time of your application if yourstudy is still in progress).
If you have spent a semester or more on exchange program in another university, have additional qualifications etc.
please specify it in the section “others”

Institution, Name of theUniversity

Major Field

Bachelor’sMaster’s

OthersType ofDiploma/
Degreeawarded

Period ofenrollment(month/year)

From/

to/

From/

to/

From/

to/

FinalGrade(GPA)

Rank inClass ifany(rank/totalstudents)(9) Employment Record Please begin with the most recent employment.
Period ofemployment(month/year)

Organization, city, country

From/

to/

From/

to/

Position

Type of work, brief description(10) List of Publications and Graduation Thesis
If you have any publications please write down a full reference information including the name(s) of the author(s),title, publisher, date of publication, pages. When DOI is available, please include it. Attach abstracts and/orreprints.
Bachelor’s thesis title:
Master’s thesis title:
List of publications (If the list is too long, please attach a separate sheet):12(11) English Proficiency
Please attach a score certificate or a medium of instruction certificate.

TOEFL, IELTS, TOEIC or other standardized English test score obtained within two years.
TestScore

Date taken (DD/MM/YYYY)☐ I have requested my TOEFL/IELTS score to be delivered directly to the e3 program’s office.

For applicants who completed full time degree in English and/or are native speakers:☐ I completed a full-time degree program which language of instruction was English.
☐ I am a native speaker of English.

(12) Have you been awarded any scholarship, grant, award or prize in the past?
If yes, please provide the details.
The name of scholarship, grant, award,prize etc

Awarding organization/fundPeriod(month/year)

FromtoFrom
toExplain briefly about thescholarship, etc.

////(16)

How did you hear about the e3 program?
We would appreciate if you not only tick a box, but also provide some further details.
☐1.e3 home page
☐3.Was advised by peers/senior student☐5.Other☐2.Was advised by my current/prospective supervisor at HU☐4.Saw e3 brochure/poster at the school

Additional details:
I understand that withholding pertinent information requested in this application form or giving false information will
make me ineligible for admission or liable for dismissal.
Signature

Date:

I support the applicant’s plan to enroll in e3
Supervisor’s signature

Date:

Postal address for submitting the application documents:
English Engineering Education program (e3)International Affairs Office of Engineering (A1-58)
Graduate School of Engineering
Hokkaido University
Kita 13 Nishi 8, Kita-ku
Sapporo 060-8628, Japan
TEL:81-11-706-8089

FOR OFFICIAL USE:
To be signed by Chairman of the Division the above applicant belongs
I agree to allow this applicant to be considered for enrolment in e3 program.
Name:
Division:Signature:Date: