For University Use

Examinee’s Registration Number

Application Form for the 2017Undergraduate International Course Program of Civil Engineering

Note:

1. This form must be completed in English and in block letters.

2. Numbers should be in Arabic figures.

3. Proper nouns should be written in full, no abbreviations.

4. This form is also available on our website in PDF format.

(1) Name of

Applicant

(as of official ID)

(Family name)

(First name)

(Middle Name)

(2)Gender ☒ Male ☐ Female

(3)Marital Status ☐ Married ☒ Single

(4)Nationality American

(5)Date of Birth (Month) (Date) (Year)

01 31 1999

Place of Birth

(6)Current Academic

Status (Name and address

of current school, etc.)

3rd-year student, XXX high school,

12345, XXXXX Avenue, XXXXX, XXXXX U.S.A.

(7)Current Address

56789, XXXXX Avenue, XXXXX XXXXX, U.S.A.

(8)Phone Number (Home) country code +1-123-XXXXX-XXXXX

(Mobile) +1-123-XXXXX-XXXXX

FAX Number +1-124-XXXXX-XXXXX

E-mail Address abc123@xyz.com

* This E-mail address is essential for communications dealing with the admission process. If the Admissions Office

has trouble contacting you, you may be placed at a disadvantage.

Form A

1.

Form A-1

XXXXXXXXXXXXXXX

SAMPLE

For University Use

Examinee’s Registration Number

(9)Educational Background (Fill in your educational background precisely in chronological order.)

Type of School Name of School Country From

(Month) (Year)

To

(Month) (Year)

Primary XXX Elementary School U.S.A. 09 2004 08 2010

Secondary XXX Junior High School U.K. 09 2010 08 2013

Secondary XXX High School U.S.A. 09 2013 08 2014

Total years of Primary and Secondary Education: ( 12 ) years ( - ) months

Undergraduate

(If available)

Name of University or College From

(Month) (Year)

To

(Month) (Year)

(10)Employment Record

Name of Company (and location) From

(Month) (Year)

To

(Month) (Year)

(11)Language Background (Indicate languages known and in which language the applicant is most proficient in.)

Name of Language Level of Proficiency

English mother tongue

Spanish fluent

(12)Person to be notified in applicant’s home country in case of emergency

Name XXXXX, XXXXX XXXXXXX Relationship Father

Address

56789, XXXXX Avenue, XXXXX, XXXXX, U.S.A.

Phone Number (Home) country code +1-123-XXXXX-XXXXX

(Mobile) +1-123-XXXXX-XXXXX

FAX Number +1-124-XXXXX-XXXXX

E-mail Address abc789@xyz.com

Form A-2

↓If less than 12 years, you need to undergo Preliminary Verification.

SAMPLE

For University Use

Examinee’s Registration Number

(13)Family or relatives in Japan (if any)

Name Relationship

Address

(14)Source (s) of payment of tuition, and living expenses in Japan (the amount of money should be indicated).

☐ Scholarship Amount /per month

(kind of currency: )

Name of Scholarship

Name and Address of

Sponsoring

Organization

☑ Family Support Amount /per month

(kind of currency: )

Name Relationship

Address

☐ Others Amount /per month

(kind of currency: )

Name Relationship

Address

☒ I am applying for “Scholarship for Undergraduate International Course Program of Civil Engineering”. *Those who wish to apply for the scholarship must check the square at the time of submission of the application

documents.

*Those who do not have college student status of residence at the time of admission are not eligible to apply or this

scholarship.

*Please note that it is basically a merit-based scholarship to be renewed every year, depending on the recipient’s

academic performance. Successful applicants will be notified individually; the scholarship amount for the first year

will be announced to each successful applicant prior to admission.

Form A-3

500USD

XXXXX, XXXXX, XXXXXXX Father

56789, XXXXX Avenue, XXXXX, XXXXX U.S.A.

SAMPLE

Form A-4

For University Use

Examinee’s Registration Number

(15)Submission of Examination Score (Choose EJU or National Standard Test)

□ EJU ( *Please be sure to enclose a copy of the Examination Voucher for the EJU.)

Examination Site Examination Date

Examination Language □ English □ JapaneseExamination

Registration Number

□ National Standard Test: Name of Test ( )

Examination Date (MM/YYYY)

Examination Language

Examination Subjects □ Mathematics for the Science Courses □ Physics □ Chemistry

□ General Science including Physics & Chemistry

In case of GaoKao*,

Examination Site

(Name of city or province):

*GaoKao: Chinese National Higher Education Entrance Examination

(16)Submission of the Score of English Proficiency Test (Dates must be indicated as MM/DD/YYYY)

□ TOEFL ( TYPE of TOEFL: )

Examination Date Score

Official Score

Ordered

□ Online at registration□ Online/Telephone/Fax/Post Mail (order date )

□ IELTS (Academic Module)

Examination Date Score

Official Score Order date

(17)Desirable Venue for the Second Screening (Interview Examination)

*Please note that applicant maybe requested to take the second screening in the country near she/he resides at the time

of the interview depending on circumstances.

Name of City Country

Date: (MM/DD/YYYY)

Signature: (*Please sign your name by hand.)

2016

EJU Scores Math 2: Physics: Chemistry:

Honors Scholarship for EJU takers I have been selected as an awardee by JASSO for 2016 university admission.

I certify that all of the information I have provided on this application form and in any accompanying documents is true.

←Examination date must be later than August 1, 2014.

←Examination date must be later than August 1, 2014.

←Sign by hand!!

✔ SAT Subject01 2015

English

✔ ✔ ✔

✔ iBT

01 07 2015 100

✔

New York U.S.A.

08 22

* *

SAMPLE