ϫ㸬ᡤᐃࡢᵝᘧ㸬ධᏛ㢪᭩㸦㝶᫬≉ู㑅ᢤ⏝㸧㸬ධᏛ㢪᭩㸦ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝㸧㸬ධᏛ㢪᭩㸦༠ᐃᰯᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝㸧㸬ᑠㄽᩥ㸬࢚ࣥࢺ࣮ࣜࢩ࣮ࢺ㸬≉ᐃ㢮ᆺヱᙜᛶࡢ⮬ᕫ⏦࿌᭩㸬ᚿᮃ⌮⏤᭩㸬᥎⸀᭩㸦ᡤᒓ㛗⏝㸧㸬⫋Ṕㄪ᭩㸬Ꮫᰯᩍ⫱➼ᒚṔ᭩㸬ཷ㦂⚊㸬ᐄྡࢩ࣮ࢺͤᡤᐃࡢᵝᘧࡣᮏᏛ࣮࣒࣮࣍࣌ࢪ㸦ࢺࢵࣉ࣮࣌ࢪЍධᏛ᱌ෆЍᡤᐃࡢᵝᘧ㸧࠿ࡽࢲ࣮࢘ࣥࣟࢻࡋࠊධຊࡋ࡚ࡃࡔࡉ࠸ࠋͤཧ⪃㸦࢖ࣥࢱ࣮ࢿࢵࢺฟ㢪Ⓩ㘓࡛Ⓩ㘓ࡉࢀࡿ㢪᭩ࡢぢᮏ㸧㸬ධᏛ㢪᭩㸦୍⯡㑅ᢤ⏝㸧㸬ධᏛ㢪᭩㸦♫఍ேࢥ࣮ࢫ≉ู㑅ᢤ⏝㸧     㸦㝶᫬≉ู㑅ᢤ⏝࣭ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸧ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ௧࿴㸴㸭㸵ᖺᗘ໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷ༤ኈ๓ᮇㄢ⛬ධᏛ㢪᭩‫ࡣ࡟ڧ‬ཷ㦂ࡍࡿ㑅ᢤヨ㦂ྡͤཷ㦂␒ྕ࡛ࢳ࢙ࢵࢡࡍࡿࡇ࡜㝶᫬≉ู㑅ᢤධᏛᕼᮃᖺ᭶‫܆‬௧࿴㸴ᖺ㸯㸮᭶෗   ┿   ‫܆‬௧࿴㸵ᖺ㸲᭶ࡓ࡚ࣇࣜ࢞ࢼ෗┿⿬㠃࡟Ặྡグධ‫⏨܆‬Ặ  ྡእᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධすᬺᖺෆㅙ῭ࡢᕼᮃᣦᑟᩍဨྡ᭶ฟ㢪๓㸱࠿᭶௨ෆ࡟᧜ᙳヨ㦂ᕼᮃ᪥኱Ꮫす ᬺ‫܆‬༞ᴗ㸦ಟ஢㸧ࡋࡓࡶࡢ᪥⏕‫܆‬㸯‫܆‬㸰‫܆‬㸱‫܆‬㸲‫܆‬㸳‫܆‬㸴‫܆‬㸵‫܆‬㸶‫܆‬㸷‫܆܆‬ฟ㢪㈨᱁ࢆ‶ࡓࡍ᭱⤊ᏛṔ↓ᖗୖ༙㌟ࠊṇ㠃ྥ࡛ࠊ‫܆‬ዪ⏕ᖺ᭶᪥⌧ఫᡤࡼࡇ㸲cm㸱cm➨㸯ᕼᮃ᪥᭶  ᪥㸦➨㸰ᕼᮃ᪥㸧᭶  ᪥㸦ເ㞟せ㡯ࡢࠕฟ㢪㈨᱁ࠖ࠿ࡽ  ࡘ㑅ᢥᏛ㒊ᖺ᭶‫܆‬༞ᴗ㸦ಟ஢㸧ぢ㎸㸧Ꮫ⛉ฟ㢪㈨᱁㸦㸷㸧ձࡢࡳグධ➨㸱ᏛᖺᅾᏛ୰㸦すᬺ ᖺ   ᭶ධᏛ㸧

ࠛ(PDLOᦠᖏ㟁ヰ⥭ᛴ᫬ࡢ㐃⤡ඛ㸦ᖐ┬ඛ➼㸧ఫᡤ  ࠛ⮬Ꮿ㟁ヰẶྡ㟁ヰ⥆᯶Ꮫ     Ṕ㧗➼Ꮫᰯ࠿ࡽグධࠋ኱Ꮫ࡟࠾࠸࡚ࡣᏛ㒊࣭Ꮫ⛉ࠊ኱Ꮫ㝔࡟࠾࠸࡚ࡣ◊✲⛉࣭ᑓᨷࡲ࡛グධࠋ኱Ꮫ➼࡛◊✲⏕࡜ࡋ࡚ᅾᏛṔࡀ࠶ࡿሙྜࡣᏛṔḍ࡟ࡑࡢᮇ㛫ࡶグධࠋධᏛ࣭༞ᴗᖺ᭶㸦すᬺ࡛グධ㸧Ꮫᰯ➼ࡢྡ⛠ᖺ᭶ධᏛ㹼ᖺ᭶‫܆‬༞ᴗ‫܆‬㸦  㸧ᖺ᭶ධᏛ㹼ᖺ᭶‫܆‬༞ᴗ‫܆‬༞ᴗぢ㎸ᖺ᭶ධᏛ㹼ᖺ᭶‫܆‬༞ᴗ‫܆‬༞ᴗぢ㎸ᖺ᭶ධᏛ㹼ᖺ᭶‫܆‬༞ᴗ‫܆‬༞ᴗぢ㎸㧗➼Ꮫᰯ㸦ᡤᅾ┴࣭ᅜ  㸧⫋     Ṕධ♫࣭㏥⫋ᖺ᭶㸦すᬺ࡛グධ㸧௻ᴗ࣭ᶵ㛵➼ྡ⛠ᖺ   ᭶㹼ᖺ  ᭶ᖺ   ᭶㹼

ᖺ

  ᭶

ᖺ   ᭶㹼ᖺ  ᭶⌧᭷⫋⪅㑅ᢥḍධᏛᚋ࡟㹙‫܆‬㏥⫋ࡍࡿ࣭‫܆‬㏥⫋ࡋ࡞࠸㹛ணᐃ࡛ࡍࠋ እᅜே␃Ꮫ⏕グධḍ ᅜ⡠༊ ศ)DPLO\Ặྡ*LYHQ
2WKHU VẶྡࡣⱥᏐ⾲グ㸦ᚲࡎ᪑ๆ࡜ྠ୍ࡢ⾲グ㸧࡛グධ‫␃㈝⚾܆‬Ꮫ⏕‫܆‬᪥ᮏᨻᗓዡᏛ㔠␃Ꮫ⏕‫܆‬እᅜᨻᗓὴ㐵␃Ꮫ⏕㸦ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝ / Recommendation for Overseas Residentsͤཷ㦂␒ྕ࣭ඛ➃⛉Ꮫᢏ⾡ᑓᨷ / Division of Advanced Science and Technology㸧

Examinee’s Number໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷ༤ኈ๓ᮇㄢ⛬ධᏛ㢪᭩ͤḍࡣグධࡋ࡞࠸ࡇ࡜ / Official use onlyApplication Form - Master’s Program / Japan Advanced Institute of Science and Technology‫ࡣ࡟ڧ‬ཷ㦂ࡍࡿ㑅ᢤヨ㦂ྡ/࡛ࢳ࢙ࢵࢡࡍࡿࡇ࡜ࠋ/ Please check the appropriate box.

ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ/Examination for Admission on Recommendation for Overseas Residents

Type of Examination‫܆‬௧࿴㸴ᖺ㸯㸮᭶ / October 2024  ‫܆‬௧࿴㸵ᖺ㸲᭶ / April 2025ධᏛᕼᮃᖺ᭶/ Admission Term෗┿ / Photographࣇࣜ࢞ࢼࡓ࡚ᛶู / GenderẶྡ / Nameࡼࡇ㸲cm×㸱cm /እᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධ‫ ⏨܆‬/ Male/ International students must write

4 cm long × 3 cm wide䖴ዪ / Female

their names in English.

    ᖺ / Year    ᭶ / Month    ᪥ / Day⏕ᖺ᭶᪥ / Date of Birthᕼᮃᣦᑟᩍဨྡ / Intended SupervisorᕼᮃࡍࡿᏛ఩㸦1 ࡘ㸧/
Degree you wish to obtain (Please select one.)‫▱܆‬㆑⛉Ꮫ / Knowledge Science‫܆‬᝟ሗ⛉Ꮫ / Information Science‫ ࢫ࢚ࣥ࢖ࢧࣝ࢔ࣜࢸ࣐܆‬/ Materials Science*ເ㞟せ㡯ࡢࠕฟ㢪㈨᱁ࠖ࠿ࡽ 1 ࡘ㑅ᢥ /‫܆‬㸯‫܆‬㸰‫܆‬㸱‫܆‬㸲‫܆‬㸳‫܆‬㸴‫܆‬㸵‫܆‬㸶‫܆‬㸷‫܆܆‬኱Ꮫྡ/University ฟ㢪㈨᱁ࢆ‶ࡓࡍ᭱⤊ᏛṔ /Eligibility Requirement

See Eligibility Requirements on the Application Guide.

Ꮫ㒊ྡ/Department‫܆‬༞ᴗ / Graduated‫܆‬༞ᴗぢ㎸ / Will graduate⌧ఫᡤ / Current Address*ᮏ㡯┠ࡣࠊ࠶ࡃࡲ࡛ࡶ㠃ㄯࡢཧ⪃࡟ࡍࡿࡶࡢ࡛࠶ࡾࠊධᏛᚋࡢ┠ᣦࡍᏛ఩࡟ࡣ୍ษᙳ㡪ࡋ࡞࠸ࠋ/ This information will be
used only for the interview and will not affect the degree youwish to obtain.

Ꮫ⛉ྡ/Majorin     ᖺ / Year    ᭶ / Monthࠛᦠᖏ㟁ヰ/ Cell Phone

Email⮬Ꮿ㟁ヰ/ Home Phone⥭ᛴ᫬ࡢ㐃⤡ඛఫᡤ / Emergency contact address  ࠛẶྡ / Name⥆᯶ / Relationship㟁ヰ / PhoneᏛ     Ṕ / Educational Background㧗➼Ꮫᰯ࠿ࡽグධࠋ኱Ꮫ࡟࠾࠸࡚ࡣᏛ㒊࣭Ꮫ⛉ࠊ኱Ꮫ㝔࡟࠾࠸࡚ࡣ◊✲⛉࣭ᑓᨷࡲ࡛グධࠋ኱Ꮫ➼࡛◊✲⏕࡜ࡋ࡚ᅾᏛṔࡀ࠶ࡿሙྜࡣᏛṔḍ࡟ࡑࡢᮇ㛫ࡶグධࠋ
Applicants must fill in their educational background starting from high school until the most recent school.
If applicable, please also write any experience as a research student at a university or other institution. Please fill in the department and faculty of the university.

ධᏛ࣭༞ᴗ㸦ぢ㎸㸧ᖺ᭶ / Period of (Expected) Attendance  Ꮫᰯ➼ࡢྡ⛠ / Name of School㧗➼Ꮫᰯ/ Secondary School

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month㸦ᡤᅾᅜ/Country     㸧⫋     Ṕ / Professional Backgroundධ♫࣭㏥⫋ᖺ᭶ / Period of Employment௻ᴗ࣭ᶵ㛵➼ྡ⛠/ Name of Organization  ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month  

ᖺ/Year  ᭶/Month 㹼   ᖺ/Year  ᭶/Month⌧᭷⫋⪅㑅ᢥḍ / Will you quit your job at the time of enrollment?
༊ศ/ᅜ⡠/ NationalityẶྡ / NameCategoryFamilyධᏛᚋ࡟㹙‫܆‬㏥⫋ࡍࡿ࣭‫܆‬㏥⫋ࡋ࡞࠸㹛ணᐃ࡛ࡍࠋ/( ‫܆‬Yes࣭‫܆‬No )‫␃㈝⚾܆‬Ꮫ⏕ / Privately financed international students‫܆‬᪥ᮏᨻᗓዡᏛ㔠␃Ꮫ⏕ / Japanese government (MEXT) scholarship students‫܆‬እᅜᨻᗓὴ㐵␃Ꮫ⏕ / Foreign government scholarship students
Given

Other (s)ゝㄒ⬟ຊ㸦⮬ᕫホ౯ࢆ excellent࣭good࣭fair࣭poor ࠿ࡽ㑅ᢥ㸧/ Language Proficiency (Evaluate the level as excellent, good, fair or poor.)ⱥ ㄒ/English

ㄞࡴ/ Reading

᭩ࡃ/ Writing⪺ࡃ/ Listeningヰࡍ/ Speaking‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor

᪥ᮏㄒ/Japanese

ㄞࡴ/ Reading

᭩ࡃ/ Writing⪺ࡃ/ Listeningヰࡍ/ Speaking‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor‫܆‬excellent ‫ ܆‬good ‫ ܆‬fair ‫ ܆‬poor     㸦༠ᐃᰯᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝࣭ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸧ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ௧࿴㸴㸭㸵ᖺᗘ໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷ༤ኈ๓ᮇㄢ⛬ධᏛ㢪᭩ཷ㦂ࡍࡿ㑅ᢤヨ㦂ྡͤཷ㦂␒ྕ‫ࡣ࡟ڧ‬࡛ࢳ࢙ࢵࢡࡍࡿࡇ࡜༠ᐃᰯᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ෗   ┿‫܆‬௧࿴㸴ᖺ㸯㸮᭶     ‫܆‬௧࿴㸵ᖺ㸲᭶ධᏛᕼᮃᖺ᭶ࡓ࡚ࣇࣜ࢞ࢼࡼࡇ㸲cm㸱cm෗┿⿬㠃࡟ẶྡグධẶ  ྡ‫⏨܆‬እᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධ↓ᖗୖ༙㌟ࠊṇ㠃ྥ‫܆‬ዪ࡛ࠊฟ㢪๓㸱࠿᭶௨ෆ

FamilyGiven⏕ᖺ᭶᪥すᬺເ㞟せ㡯ࡢࠕฟ㢪㈨᱁ࠖ࠿ࡽ  ࡘ㑅ᢥ‫܆‬኱Ꮫ    ‫܆‬㧗➼ᑓ㛛Ꮫᰯ‫܆‬㸦   㸧ฟ㢪㈨᱁ࢆ‶ࡓࡍ᭱⤊ᏛṔ࡟᧜ᙳࡋࡓࡶࡢ    ᖺ    ᭶    ᪥⏕>せ௳ $@‫܆‬㸯‫܆‬㸰‫܆‬㸱すᬺ⌧ఫᡤOther(s)‫܆‬Ꮫ㒊‫܆‬ᑓᨷ⛉‫܆‬㸦 ᖺ᭶‫܆‬Ꮫ⛉‫܆‬ᑓᨷ‫܆‬㸦   㸧㸧༞ᴗ㸦ಟ஢㸧ぢ㎸ࠛ(PDLOᦠᖏ㟁ヰ⥭ᛴ᫬ࡢ㐃⤡ඛ㸦ᖐ┬ඛ➼㸧ఫᡤ  ࠛ⮬Ꮿ㟁ヰẶྡ㟁ヰ⥆᯶Ꮫ     Ṕ㧗➼Ꮫᰯ࠿ࡽグධࠋ኱Ꮫ࡟࠾࠸࡚ࡣᏛ㒊࣭Ꮫ⛉ࠊ኱Ꮫ㝔࡟࠾࠸࡚ࡣ◊✲⛉࣭ᑓᨷࡲ࡛グධࠋධᏛ࣭༞ᴗᖺ᭶㸦すᬺ࡛グධ㸧ᖺ᭶ධᏛ㹼Ꮫᰯ➼ࡢྡ⛠ᖺ‫܆‬༞ᴗ᭶‫܆‬㸦  㸧ᖺ᭶ධᏛ㹼ᖺ‫܆‬༞ᴗ᭶‫܆‬༞ᴗぢ㎸ᖺ᭶ධᏛ㹼ᖺ᭶‫܆‬༞ᴗ‫܆‬༞ᴗぢ㎸ᖺ᭶ධᏛ㹼ᖺ᭶‫܆‬༞ᴗ‫܆‬༞ᴗぢ㎸㧗➼Ꮫᰯ㸦ᡤᅾ┴࣭ᅜ  㸧⫋     Ṕධ♫࣭㏥⫋ᖺ᭶㸦すᬺ࡛グධ㸧௻ᴗ࣭ᶵ㛵➼ྡ⛠ ᖺ᭶㹼ᖺ᭶ ᖺ᭶㹼ᖺ᭶ ᖺ᭶㹼ᖺ᭶እᅜே␃Ꮫ⏕グධḍ ᅜ⡠༊ ศ)DPLO\Ặ

ྡ

*LYHQ
2WKHU VẶྡࡣⱥᏐ⾲グ㸦ᚲࡎ᪑ๆ࡜ྠ୍ࡢ⾲グ㸧࡛グධ‫␃㈝⚾܆‬Ꮫ⏕‫܆‬᪥ᮏᨻᗓዡᏛ㔠␃Ꮫ⏕‫܆‬እᅜᨻᗓὴ㐵␃Ꮫ⏕（先端科学技術専攻）

小論文※欄は記入しないこと。

※受験番号「本学入学後に取り組みたい研究課題について」

注 文中に出身大学名、出身大学の指導教員名、勤務先名は記入しないこと。
裏面の使用及び補足資料の添付不可。

氏名：（外国人留学生は英字で記入）

北陸先端科学技術大学院大学先端科学技術研究科先端科学技術専攻

 㸦ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸧                                  ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ
ͤཷ㦂␒ྕ࢚ࣥࢺ࣮ࣜࢩ࣮ࢺὀ ඲࡚ࡢ㡯┠ࡣグධᚲ㡲࡛࠶ࡿࠋグ㍕ෆᐜࡣ࠶ࡃࡲ࡛ࡶ㠃᥋ࡢཧ⪃࡟ࡍࡿࡶࡢ࡛࠶ࡾࠊධᏛᚋࡢ◊✲ᐊ㓄ᒓࠊ┠ᣦࡍᏛ఩࡟ࡣ୍ษᙳ㡪ࡋ࡞࠸ࠋẶ ྡ㸸㸦እᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධ㸧ձ㛵ᚰࡢ㧗࠸◊✲㡿ᇦ
㸦10 ◊✲㡿ᇦ࠿ࡽ 1 ࡘ㸧ͤ♫఍ேࢥ࣮ࢫ≉ู㑅ᢤࡣࠊ
3 ࣉࣟࢢ࣒ࣛ࠿ࡽ 1 ࡘղ㛵ᚰࡢ㧗࠸◊✲ᐊ➨㸯㡰఩

㸦1 ྡ௨ୖ㸧➨㸰㡰఩ͤᩍဨྡࢆࣇࣝࢿ࣮࣒࡛グ㍕ ➨㸱㡰఩ճᕼᮃࡍࡿᏛ఩㸦1 ࡘ㸧‫▱܆‬㆑⛉Ꮫ  ‫܆‬᝟ሗ⛉Ꮫ  ‫ࢫ࢚ࣥ࢖ࢧࣝ࢔ࣜࢸ࣐܆‬մᚓព࡞ᑓ㛛⛉┠㸦3 ⛉┠ᚲ㡲㸧յᮏᏛࢆᚿᮃࡍࡿ⌮⏤ᩥ୰࡟ฟ㌟኱Ꮫྡࠊฟ㌟኱Ꮫࡢᣦᑟᩍဨ
ྡࠊ໅ົඛྡࡣグධࡋ࡞࠸ࡇ࡜ࠋ
⿬㠃ࡢ౑⏝ཬࡧ⿵㊊㈨ᩱࡢῧ௜୙ྍࠋ

նᮏᏛ༤ኈ๓ᮇㄢ⛬ಟ஢ᚋࡢ࢟ࣕࣜ࢔┠ᶆ
ᩥ୰࡟ฟ㌟኱Ꮫྡࠊฟ㌟኱Ꮫࡢᣦᑟᩍဨ
ྡࠊ໅ົඛྡࡣグධࡋ࡞࠸ࡇ࡜ࠋ
⿬㠃ࡢ౑⏝ཬࡧ⿵㊊㈨ᩱࡢῧ௜୙ྍࠋ໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷ≉ᐃ㢮ᆺヱᙜᛶ䛾⮬ᕫ⏦࿌᭩㻛 Self-Declaration Form of Applicability to a Specific Category
እᅜⅭ᭰ཬࡧእᅜ㈠᫆ἲ㸦௨ୗࠕእⅭἲࠖ࡜࠸࠺ࠋ㸧࡟ᇶ࡙ࡁࠊつไᑐ㇟࡜࡞ࡿ㈌≀ࡢ㍺ฟࡸᢏ⾡ࡢᥦ౪࡟ࡘ࠸࡚⤒῭⏘ᴗ኱⮧ࡢチྍࢆཷࡅࡿ⩏ົࡀㄢࡏࡽࢀ࡚࠸ࡿࡇ࡜࠿ࡽࠊᮏᏛ࡛ࡣࠕᅜ❧኱Ꮫἲே໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱ᏛᏳ඲ಖ
㞀㍺ฟ⟶⌮つ๎ࠖࢆᐃࡵࠊᏳ඲ಖ㞀㍺ฟ⟶⌮࡟ྲྀࡾ⤌ࢇ࡛࠾ࡾࡲࡍࠋ
Ᏻ඲ಖ㞀㍺ฟ⟶⌮࡛ࡣࠊ㠀ᒃఫ⪅㸦᪥ᮏධᅜᚋ㸴᭶ᮍ‶ࡢᏛ⏕➼㸧࡬ࡢᢏ⾡➼ࡢᥦ౪࡟ຍ࠼ࠊᒃఫ⪅㸦᪥ᮏධᅜᚋ㸴᭶௨ୖ⤒㐣ࡋࡓᏛ⏕➼㸧࡛࠶ࡗ࡚ࡶ㠀ᒃఫ⪅ࡢ㠀ᖖ࡟ᙉ࠸ᙳ㡪ୗ࡟࠶ࡿሙྜࠊࡑࡢࡼ࠺࡞ᒃఫ⪅㸦≉ᐃ㢮ᆺヱᙜ⪅㸧࡟ᑐࡍࡿᢏ⾡➼ࡢᥦ౪࡟ࡘ࠸࡚ࡶࠕࡳ࡞ࡋ㍺ฟࠖ࡜ࡋ࡚⟶⌮ࡢᑐ㇟࡜࡞ࡾࡲࡍࠋ
ࡇࡢࡇ࡜࠿ࡽࠊᮏᏛ࡬ࡢฟ㢪ࢆᕼᮃࡍࡿ᪉࡟ࡣእⅭἲ࡟ᇶ࡙ࡃࠕࡳ࡞ࡋ㍺ฟࠖ࡟࠾ࡅࡿ⟶⌮ᑐ㇟࡛࠶ࡿ࠿࡝࠺࠿ࡢ⮬ᕫ⏦࿌ࢆ࠾㢪࠸ࡋ࡚࠾ࡾࡲࡍࠋࡈ⮬㌟ࡢ≧ἣ࡟ࡘ࠸࡚ࠊู⣬ࡢࣇ࣮ࣟࢳ࣮ࣕࢺࢆཧ↷࠸ࡓࡔࡁࠊኴᯟෆࢆグධࡢୖࠊฟ㢪᭩㢮࡜ేࡏ࡚ࡈᥦฟࡃࡔࡉ࠸ࠋ
Since any export of goods or transfer of technologies subject to the controls requires a license from the Minister ofMETI (the Ministry of Economy, Trade and Industry) based on the Foreign Exchange and Foreign Trade Act (hereafterreferred to as “FEFTA”), JAIST has established regulations for Security Export Control and we are working on it.
 Transferring technologies, etc. to a none-resident (a student who has been staying in Japan for 6 months or less, etc.)
and to a resident ( a student who has been staying in Japan for 6 months or more, etc.) who is under the significant
influence of a non-resident, (a person who falls under the specific category), are subject to control as “deemed exportcontrol”.
 We ask all applicants for admission to self-declare whether or not they are subject to the "deemed export control"
based on the FEFTA. Please refer to the attached flowchart, fill in the form and submit it along with your application
documents.

㸦ὀ㸯 / Note 1㸧እᅜே␃Ꮫ⏕ࡣẶྡࢆⱥᏐ࡛グධࡍࡿࡇ࡜ࠋ / International students must write their names in English.

グධᖺ᭶᪥ / Date       ᖺ / Year     ᭶ / Month     ᪥ / DayẶྡ /Name㸦ὀ㸯 / See Note 1㸧ㄢ⛬Program‫܆‬༤ኈ๓ᮇㄢ⛬Master’s Program(Place a check mark in the appropriate box.㸧 ‫܆‬༤ኈᚋᮇㄢ⛬Doctoral Program≉ ᐃ 㢮 ᆺ ヱ ᙜ ᛶ ࡢ ⮬ ᕫ ⏦ ࿌ / Self-‫܆‬㢮ᆺձ࡟ヱᙜ / I fall under the category 1

Declaration of Applicability to a SpecificCategory‫܆‬㢮ᆺղ࡟ヱᙜ / I fall under the category 2‫܆‬㢮ᆺձղࡢ୧᪉࡟ヱᙜ / I fall under the category 1 and 2(Place a check mark in the appropriate box.㸧‫ࡶ࡟ࢀࡎ࠸܆‬ヱᙜࡋ࡞࠸ / I do not fall under any of the categories㸦ู⣬$SSHQGL[㸧ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ     㸦ᾏእᅾఫ⪅ᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝࣭ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸧     ͤཷ㦂␒ྕᚿᮃ⌮⏤᭩    グධ࡟࠶ࡓࡗ࡚ࡢὀព㸸    ኱Ꮫ࣭㧗➼ᑓ㛛Ꮫᰯ࡟ᅾᏛ୰࡟⯆࿡ࢆࡶࡗࡓ◊✲ࡸྲྀࡾ⤌ࢇ࡛ࡁࡓ◊✲ࠊᚓព⛉┠ࠊᮏᏛධᏛᚋࡢᢪ㈇ཬࡧ኱Ꮫ㝔ಟ஢ᚋ࡟ά㌍ࡋࡓ࠸ศ㔝࡞࡝࡟ࡘ࠸࡚ᯟෆ࡟཰ࡲࡿࡼ࠺࡟グ㏙ࡍࡿࡇ࡜㸦⮬⏤グ㏙㸧ࠋẶ ྡ㸸㸦እᅜே␃Ꮫ⏕ࡣⱥᏐ࡛グධ㸧໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸦༠ᐃᰯᑐ㇟᥎⸀ධᏛ≉ู㑅ᢤ⏝࣭ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸧       ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋͤཷ㦂␒ྕ  ᖺ  ᭶  ᪥  ᥎   ⸀   ᭩  ໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫ㛗 ᐄᡤ ᅾ ᆅ ࠛ    㸫                        㟁   ヰ 㸦     㸧   㸫         Ꮫ ᰯ ྡ              ኱Ꮫ࣭▷ᮇ኱Ꮫ࣭㧗➼ᑓ㛛Ꮫᰯ࣭኱Ꮫᰯᡤᒓ㛗⫋࣭Ặྡ                       බ༳  ୗグࡢ⪅࡟ࡘ࠸࡚ࠊ᥎⸀⌮⏤ࡢ࡜࠾ࡾࠊே≀ཬࡧᏛຊ࡟㛵ࡋඹ࡟ඃ⚽࡜ㄆࡵࡽࢀࡿࡇ࡜࠿ࡽࠊ㈐௵ࢆࡶࡗ࡚᥎⸀࠸ࡓࡋࡲࡍࠋグᚿ㢪ඛඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷᚿ㢪⪅Ặྡ ᥎⸀⌮⏤ͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ     㸦♫఍ேࢥ࣮ࢫ≉ู㑅ᢤ⏝࣭ඛ➃⛉Ꮫᢏ⾡ᑓᨷ㸧ͤཷ㦂␒ྕ      ⫋Ṕㄪ᭩     㐣ཤ࣭⌧ᅾࡢ⫋Ṕཬࡧࡑࡢ⫋ົෆᐜ ࡸ◊✲ෆᐜ ࡟ࡘ࠸࡚ࠊᯟෆ࡟཰ࡲࡿࡼ࠺グ㏙ࡍࡿࡇ࡜㸦⮬⏤グ㏙㸧ࠋ࡞࠾ࠊᮏࢥ࣮ࢫ࡬ࡢධᏛ࡟ᙜࡓࡾ⫋ົ⤒㦂࡟ࡘ࠸࡚࢔ࣆ࣮ࣝࡋࡓ࠸Ⅼࡀ࠶ࢀࡤࠊేࡏ࡚グ㏙ࡍࡿࡇ࡜ࠋẶ ྡ㸸㸦እᅜ⡠ࡢᚿ㢪⪅ࡣⱥᏐ࡛グධ㸧 ໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉ඛ➃⛉Ꮫᢏ⾡ᑓᨷͤḍࡣグධࡋ࡞࠸ࡇ࡜ࠋ
Official use onlyͤཷ㦂␒ྕᏛᰯᩍ⫱➼ᒚṔ᭩
Curriculum VitaeධᏛᕼᮃᖺ᭶
Semester for which
you are applyingᚿᮃㄢ⛬
Intended program

Examinee’s Number‫ڧ‬௧࿴㸴ᖺ㸯㸮᭶‫ڧ‬௧࿴㸵ᖺ㸲᭶October 2024

April 2025༤ኈ๓ᮇㄢ⛬
Master’s Program⏕ᖺ᭶᪥
Date of BirthYearMonthDayẶྡ
Full name inEnglish

FamilyGivenOther(s)㹙Ꮫ Ṕ Educational Background㹛ᏛᰯྡཬࡧᡤᅾᆅName and location of schoolṇつࡢಟᏛᖺᩘ

ධᏛཬࡧ༞ᴗᖺ᭶

ಟᏛᖺᩘ

Officially requiredYear and month of enrollment andDuration of

number of years

graduation or completionattendanceof schoolingึ➼ᩍ⫱Primary EducationᏛᰯྡධᏛ   㸭

NameFromYear

Ꮫ఩࣭㈨᱁
Qualification(degree, diplomaor certificate)ᖺMonthyearsandᑠᏛᰯᡤᅾᆅPrimary SchoolLocation

ToYearyearsᏛᰯྡධᏛ   㸭

NameFromYearLowerᡤᅾᆅᖺ ༞ᴗ  㸭ToYearyearsᏛᰯྡධᏛ   㸭㧗ᰯName

FromYearUpperᡤᅾᆅ୰Ꮫཬࡧ㧗ᰯ㧗➼ᩍ⫱᭶   months

Monthyears

ᖺMonth᭶   months

Monthyears

ᖺandLocation

Higher Education

MonthandLocation

SecondarySchool  㸭୰Ꮫ୰➼ᩍ⫱Secondary
Educationᖺ ༞ᴗᖺ ༞ᴗ  㸭ToYearyearsᏛᰯྡධᏛ   㸭

Name

From

YearMonth᭶   months

Monthyears

ᖺand኱Ꮫ

ᡤᅾᆅ

Undergraduate Level

Location኱Ꮫ㝔Graduate Levelᖺ ༞ᴗ  㸭

ToYearyearsᏛᰯྡධᏛ   㸭

Name

FromYearMonth᭶   months

Monthyears

ᖺandᡤᅾᆅ
Locationᖺ ༞ᴗ  㸭ToYearyearsMonth᭶   months

ᖺ
years

௨ୖࢆ㏻⟬ࡋࡓ඲Ꮫᰯᩍ⫱ಟᏛᖺᩘ

andTotal years of the schooling mentioned above᭶   months

ᖺ
years

ὀ㸧ୖḍ࡟᭩ࡁࡁࢀ࡞࠸ሙྜ࡟ࡣࠊ㐺ᐅู⣬࡟グධࡋ࡚ῧ௜ࡍࡿࡇ࡜ࠋIf the given space is not enough, attach additional sheets.

㹙⫋ Ṕ Professional Background㹛໅ົඛཬࡧᡤᅾᆅName and location of organization໅ົᮇ㛫Period of employment

FromToFromToFromToFromToὀ㸧⹫ഇࡢ஦㡯ࢆグ㍕ࡋࠊཪࡣᙜ↛グ㍕ࡍ࡭ࡁ஦㡯ࢆグධࡋ࡞࠿ࡗࡓࡇ࡜ࡀุ᫂ࡋࡓሙྜࡣࠊධᏛチྍࢆྲྀࡾᾘࡍࡇ࡜ࡀ࠶ࡿࠋ
If it is discovered that an applicant has made false statements or has neglected matters to be stated on this curriculum vitae, the admission may
be revoked even after enrollment.

㹙᪥ᮏᅾఫ㐃⤡ே㹛እᅜᅾఫࡢ᪉ࡢࡳグධࡋ࡚ࡃࡔࡉ࠸ࠋ For applicants living overseas, please fill out a contact person in Japan (if any).
Ặྡฟ㢪⪅࡜ࡢ㛵ಀFull Name

Relationship to the applicantఫᡤAddress㟁ヰ␒ྕ㟁Ꮚ࣓࣮ࣝ

Phone:Email:ཷ  㦂  ⚊([DPLQDWLRQ$GPLVVLRQ&DUG໭㝣ඛ➃⛉Ꮫᢏ⾡኱Ꮫ㝔኱Ꮫඛ➃⛉Ꮫᢏ⾡◊✲⛉Japan Advanced Institute of Science and Technology
Graduate School of Advanced Science and Technology                          ෗    ┿ཷ 㦂 ␒ ྕ
Examinee’s Number

Photographࡓ࡚  ࡼࡇࣇ ࣜ ࢞ ࢼLongwide㸲cm㸱cm㢪᭩࡜ྠ୍ࡢࡶࡢAttach the sameẶ   ྡphoto as in yourFull Nameapplication

ヨ 㦂 ᪥ヨ 㦂 ᐊཷ௜᫬㛫ヨ㦂᫬㛫Examination Date

Examination RoomRegistration Time

Examination Time     㸸᭶᪥monthday➨ No.

ヨ㦂ᐊRoom   㹼 㸸   㸸ᮏ⚊ࡣཷ㦂ࡢ㝿ࠊᚲࡎᦠᖏࡍࡿࡇ࡜ࠋ
Applicants must bring this card on the day of the examination.
ᮏ⚊ࡣධᏛᡭ⥆᫬࡟ࡶᚲせ࡞ࡢ࡛ࠊ ヨ㦂ᚋࡶಖ⟶ࡋ࡚࠾ࡃࡇ࡜ࠋ
After the examination, please keep this card for the future entrance procedures.
ᡤᐃࡢᯟ࡟෗┿ࢆ㈞௜ࡍࡿࡇ࡜ࠋࡲࡓࠊኴᯟෆࡢࡳグධࡍࡿࡇ࡜ࠋ
Please fill only in the thick frame and attach photos.

㹼㸸ࠛ     ̿      ࠛ     ̿      ఫᡤ$GGUHVVఫᡤ$GGUHVV                                                                                Ặྡ1DPHẶྡ1DPH                   ᵝ                     ᵝࠛ     ̿      ࠛ     ̿      ఫᡤ$GGUHVVఫᡤ$GGUHVV                                                                                Ặྡ1DPHẶྡ1DPH                   ᵝ                    ᵝࠛ     ̿      ࠛ     ̿      ఫᡤ$GGUHVVఫᡤ$GGUHVV                                                                                Ặྡ1DPHẶྡ1DPH                   ᵝ                    ᵝࠛ     ̿      ࠛ     ̿      ఫᡤ$GGUHVVఫᡤ$GGUHVV                                                                                Ặྡ1DPHẶྡ1DPH                   ᵝ                    ᵝ