Request form for JLPT Certificate of Result and Scores for those who took the test in

Japan

Send me the Certificate of Result and

Scores.
Please fill out the thick squared area.

Name Roman letters

Address in Japanese or English

Telephone Number

Date of Birth

year
month
day

The year and month you took the

JLPT

year
month

Test Site (Only in Japan)

Registration Number

Number of

Issuance Fee

Mailing Fee

1,000

A. 0
(Ordinary mail in Japan)
B. 500

(Express mail in Japan)

C. 1,000
(Receive the Certificate
abroad)

Please circle only one.

Total Cost

Copies

If you apply for the Certificate in Japan, please send the total cost by Postal Money Order.

If you apply for the Certificate from abroad, please send the total cost by International Postal Money
Order.

Please also enclose the following item.

Check

A photocopy of the Test Result or Certificate of Japanese-Language

Proficiency

A photocopy of your passport on which the year of the test is indicated if you lost them.