E J

Be sure to send your application via tracked service, such as resigtered mail (i.e. EMS, , Letter Pack)If you are unable to submit some documents by the dealine, or plan to submit documents afterwords, please include a momo

(Your estimated) Submission Deadline for the extra documents

N a m e

Student No. Laboratory Ext.

Address in Japan

Adviser's Signature and Seal(enrollment year)

Master's course Doctral course Medicine Dentisitry

Graduate school

Undergraduate

Faculty

N a m e Student Number

Family members living together in Japan only

Instruction for Completing Tuition Waiver Application Form (Example)

The application for tuition waiver will be used only for the screening procedure for tuition waiver. Fill in truthfully, by yourself.If intentional descriptions different from the fact are found,the tuition waiver will be canceled even after the approval.

Fill in the situation as of April for the 1st semester and October for the 2nd semester.

For the items marked with , encircle the appropriate items.

Fill in the "Reasons for Difficulty in Tuition Payment" including the following items.

Special circumstances

Independent livelihood financial situation

Situation of persons under long-term medical treatment

Detailed situation of damage by disaster, etc.

Foreign students' life situation in Japan

When you are unemployed, indicate how you cover your cost of living, the prospect of reemployment, etc.

Date of submission of application documents.

To be signed by the applicants

Attach the required documents.

Fill in the address, phone number and e-mail address that will be applicable after the application. Leave it blank if you don't know them at the time of application.

Leave the student No. blank if you don't know your new student No. at the time of application.

To be signed by adviser. Signed or sealed by proxy are not acceptable.

Please use blue or black pen only (pencil or erasable pen are not acceptable).

N a m e

Student No. Laboratory Ext.

Address in Japan

Adviser's Signature and Seal(enrollment year)

Master's course Doctral course Medicine Dentisitry

Graduate school

Undergraduate

Faculty

Instruction for Completing Tuition Waiver Application Form

N a m e Student Number

Family members living together in Japan only

Occupation of your family member(s) living together in Japan

If you or family member(s) living together in Japan have the Identification booklet for the physically disabled certificate, fill in the name and level.If you or family member(s) living together in Japan are on long-term medical treatment, fill in the name and submit the most recent six months of receipt of medical treatment.

Enter the necessary items so as to copy them in the duplicate sheet. Submit the sheets without separating them.

For the items marked with , encircle the appropriate items.

Do not fill in the items inside the thick line frame. These items are the official use only.

Scholarship benefits to be received or expected to be received during this academic year (from April to

Foreign students paying their own tuition must fill in the information about ONLY family members living together in Japan.

Left-align the Student No.

This is for Japanese students only

Foreign students paying their own tuition must choose 1

Family members (living together in Japan) enrolled in school as of April (April enrollment) and as of

Please use blue or black pen only (pencil and erasable pen are not acceptable)

This is for Japanese students only

Official Use Only

Official Use Only

Official Use Only

Form A

TOHOKU UniversityDocument for Admission / Tuition Fee Waiver Application

Student No.

NAME

E

TOHOKU University Document for Admission / Tuition Fee Waiver Application

Payment Slip Attachment Sheet

Name of the income earner

Relationship with the applicant

Type of Employment

/ Full-time employee Part-time employee Other

Student No

Name

Form 1

TOHOKU University Document for Admission / Tuition Fee Waiver Application

2020 1

/ (

3

3 3

(

)

12

2021 4 2022 3

Student No.

Name

This form must be filled out by the person in charge of the employment.

Form 5

To President,

I declare the following information to be factual and accurate.

Other Other

Total Total

Income

Occupation / School

Utilities

Fill out your financial situation as of April 2021 1st semester) or October 2021 (2nd semester).

Average Living Expensesper Month

Statement of the Financial Situation

Family members living in Japan

Surname Given name

Books, school supplies(excluding tuition fee)

Transportation andCommunication

Food

Expenditure

Important The balance between income and expenditure must be even or income must be more than expenditure.

TA/RA

Indicate the financial situation in Japan (calculated in Japanese yen) accurately.

Item

Housing(include management /

maintenance fee)

Scholarship(family member)

Scholarship (applicant)

Child Care

Insurance /Medical Care

Part-time work(family member)

Daily necessities

Part-time work(applicant)

Name

Adviser's remark:PC

Self-financed / Moneybrought from home

TOHOKU University Document forAdmission/Tuition Fee Waiver Application

Student ID Number

RelationshipLiving

together/separately

(seal)

ItemAverage Income per Month

Remittances / Financialsupport from family, etc.

(Adviser's Signature

Age

Form7 To be filled out by foreign students paying their own tuition

TOHOKU University Document for Admission/Tuition Fee Waiver Application

Statement for Accommodation Situation

Indicate your accommodation type

(International House/University House) (Public Housing) (Private Apartments/Houses) (Other)

(Rent per Month)

If the applicant is living in private apartment or public housing, please submit a copy of the contract of lease.

If the applicant is sharing a room, or does not have a contract of lease for his/her accommodation, please fill out the “Conditions of Lease Contract” below.

If the applicant does not pay rent, shares the rent with roommate or pays less than the full monthly rent, please describe the situation in the “Other Information”.

Conditions of Lease Contract of your Accommodation

Address

Lessee

Relationship with Applicants

( )

Person(s) living with Lessee other than

applicant

Yes ( Name Relationship with Lessee

No

Rent per Month

Include Common Area Fee

(Applicant’s share)

Other Information

Please submit a copy of the contract of lease (photocopy).

( ) I declare the above information to be factual and accurate. (Must be signed by the person who rent the apartment)

Lessee Signature

( ) Phone No.

Student Number

NName

東北大学 授業料免除申請の添付書類

授業料免除に係る「特別の事由」の説明書

学籍番号(Student Number)

氏 名(Name)

（ 年 月入学・編入学・進学）

留年、又は修業年限を超えて在籍している学生は、免除申請をすることができません。 ただし、学校

が認めた休学や留学、病気など、特別な事由があると認められ、かつ学業の基準を満たす場合は、原則と

して１年間に限り免除申請ができます。

○ 休学期間 年 月 日～ 年 月 日（病気・留学・自己都合）

※大学等が定める正規の手続きを経て認められた休学期間を記入してください。

○ 休学期間に満たない期間の病気・怪我 年 月 日～ 年 月 日

※診断書または治療費の領収書等、確認できる書類を添付してください。

○ 留学期間(Period of studying abroad) 年 月 日～ 年 月 日

プログラム名 Name of the program （ ）

〇 留学先 ①Country（ ）

②Name of the school / faculty（ ）

特別の事由の説明（留年又は修業年限超過に至った理由を詳しく明確に記入すること。） Specify the special circumstances that caused you repeating a year

学籍番号(Student Number)

氏 名(Applicant’s Name)

特別の事由の説明に対する意見（Adviser’s Remarks）

通常、留年し又は最短修業年限を超えて在籍している学生は、免除申請をすることができませんが、

休学・病気・留学など「特別な事由」があると認められる場合には、原則１年間に限り免除申請ができ

るため、指導教員の先生に「特別の事由」に対する意見を求めるための様式です。

また、正規最短修業年限を、２年を越えて在籍している学生の場合は、本人の責に依らない真にやむ

を得ない事情がある場合に限り免除申請ができます。その点にご留意いただき意見を記載いただくよう

お願いします。

指導教員等（自署） 印

留年又は修業年限超過に至った理由

免除対象区分等（大学事務担当記入欄）

必要に応じて切り離してご記入ください。

但し、原則として申請者本人が合わせて提出してください。

東北大学 授業料免除申請の添付書類

※原則として、指導教員の先生が自筆で記入をお願いします。PC での記入も可としますが、自署・押印が必要です。

Note: This form must be written by the applicant’s adviser. Typing is permitted but this form is not valid without the adviser’s signature and personal seal.

（内線番号 ） 記入の内容について、確認のご連絡をする場合があります。

様式８－１ Form8-1 Tohoku University Document for Tuition Fee Waiver Application

Statement of Special Reasons

Year and month of enrollment of Tohoku University

Period you took an approved leave from school (illness / study abroad / personal reasons)

Period you are unable to study because of illness or injury

Doctor’s medical certificate or receipts of medical expense must be submitted

東北大学 授業料免除申請の添付書類 様式８－２ Form8-2

Tohoku University Document for Tuition Fee Waiver Application

11 Form 11

Tohoku University Document for Admission / Tuition Fee Waiver Application

TA RA Certificate of (expected) TA/RA Payment

This is to certify the applicant’s working condition and income situation of TA/RA. Please certify the facts as stated below.

TA RA AA

20 4 1 20 9 30 6 300,000

It is not necessary to submit this form when there are other documents that certify the entire information above.

This form must be filled out by the person, faculty or the office in charge of the employment.