ࡱ> c Rbjbj**HSbHSbA2, nn8.L***:: :JJJJJJJ$ObR^ K:#:::: Knn**K???:nR**J?:J??VcF@"G*7) =RF JK0LFTR=TGGRT$G::?::::: K K?:::L::::T::::::::: R 4: èƵ Application form for IU-SEP èƵ Student Exchange Program INSTRUCTIONS 1. The Form should be filled out either in Japanese or English. 2. Please write in block letters when using English. 3. Numbers should be in Arabic figures.  PERSONAL INFORMATION 1. Applicant's name: ; In capital letters, as shown on your passport Family Name / Given Name 2. Applicant's name in  "oW[ (If you have): 3. Applicant's name in  u00L0j0 (If you know): 4. Passport number: 5. Gender: & Male & Female 6. Nationality: 7. Place of Birth: (City, Province/State, Country) 8. Date of Birth (Month/ Day/Year): month day year 9. Mailing Address (in full): *Write in English 10. Zip Code: 11. TEL: 12. E-mail: ; All notification concerning application procedures will be done by e-mail, so please choose one you regularly use. 13. When are you planning to study at Iwate University? Starting Semester: &0Spring Semester ( from 1 April ) &0Fall Semester ( from 1 October ) Length of Study : &01 Semester ( 6 months ) &02 Semesters ( 1 year ) ; Length of study at Iwate University should not exceed your expected date of graduation at home university. EMERGENCY CONTACT INFORMATION 1. Guardian's Name: 2. Relationship: 3. Guardian's Address: 4. Guardian's TEL: 5. Guardian's E-mail: HOME INSTITUTION INFORMATION (University you belong to in your home country.) 1. Name of University: 2. Department/Major: 3. What year will you be when you come to èƵ? & Sophomore (2nd year) & Junior (3rd year) & Senior (4th year) & Master Course ( year) & Doctoral Course ( year) 4. When did you enter your home institution? Month/ Year 5. When do you expect to graduate from your home institution? Month/ Year 6. Name of the applicant's advisor: 7. Adviser's TEL: E-mail: 8. Address of your home institution (or the office in charge of student exchange program): *Application-acceptance notification will be sent to this address. Contact Personnel: TEL: Address: Office Name / Number / Street City / State / Zip Code / Country Contact Personnel's E-mail: HEALTH RECORD 1. Are you currently receiving treatment for illness or injury? & Yes please explain & No 2. Are you currently taking medications? & Yes which medicines & No 3. Do you have any health concerns? & Yes please explain & No 4. Have you ever been hospitalized due to illness or injury? & Yes please explain & No 5. Have you ever seen a doctor regularly for more than 1 month because of illness or injury? & Yes please explain & No 6. Have you ever had mental health problems? & Yes please explain & No 7. Please let us know if you require any special assistance:  LANGUAGE ABILITY 1. Have you studied Japanese before? & YES & NO (We don t require the applicants to be proficient in Japanese, but it is helpful for us to know your knowledge of the language before you arrive.) 2. If you answered Yes, please write the history of your Japanese language training. Name of School/Training InstitutionNumber of classes per weekLength of training 3. Your language skills Language abilityReadingWritingSpeakingListeningJapaneseEnglishOthers ( )Rate on a scale of 3 to 0. 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Please list the names of the courses you are planning to take (the courses can be changed after you come to Iwate University). You may view our course offerings on the following website: https://www.iwate-u.ac.jp/iuic/english/international-students/types-of-programs/student-exchange-program-iu-sep.html Mandatory Core Courses (Language/Research) Elective Courses/Optional CoursesPlease describe the outline of your research field. ; If you are graduate student, please fill out the Research Plan on the last page.  FINANCIAL SOURCE AND SUPPORT What will be your main financial source while you study in this Program (Check one of following): % Personal Fund % Student Loan % Scholarship or Funds (Please specify.) Name of Fund or Scholarship 0000Monthly amount: yen JASSO Scholarship Applicants (of the Humanities course and the Artistic course only) may apply for a scholarship (\80,000/month) of Japan Student Service Organization (JASSO). Note that the scholarship is competitive and not all the applicants can receive the scholarship. ; Applications must have a grade point average of 2.3 or higher out of 3.0 points on JASSO evaluation scale. (See the Note on the application guide.) 1. Do you wish to apply for the JASSO scholarship? % YES % NO 2. If your JASSO scholarship application is rejected, you will: % withdraw from IU-SEP program % still participate in IU-SEP program NOTE It is very difficult for short-term students to find a part-time job if they are not fluent in the Japanese language. Therefore, please prepare enough financial resources to support your stay and study in Japan. You will need to prepare at least 80,000 Japanese yen per month. In the case that you do not have enough financial support, you will not be accepted in the program. % I have read and agree with the above NOTE. PLEDGE I declare that the information contained in this application is complete, accurate and true to the best of my knowledge. Applicant's Signature: Date: Month / Day/ Year ; Please return your complete application form to  HYPERLINK "mailto:gryugaku@iwate-u.ac.jpvia" gryugaku@iwate-u.ac.jp via e-mail. RESARCH PLAN0For Graduate Student Only ; Please describe your Field of Study and Research Plan concretely and in detail because it will serve as important material for placement of the applicant at Iwate University. Present field of study Describe articulately the research you wish to carry out at Iwate University. 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