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Please type all entries, handwritten applications will not be accepted.

University of the Ryukyus Short-Term Student Exchange Program (URSEP)
APPLICATION PACKAGE Please use this sheet as the cover page for your application package. Date: 02 (Month) 01 (Day) 2012 (Year) Name of Applicant: Ardianto Kurniawan Home Institution: Diponegoro University <Information about the International Student Office of your Home Institution> ① Name of the Person-in-Charge:     ② Address: ③Phone Number:                ④ Fax Number: ⑤ E-mail:           This application should be sent as a complete package containing all the following documents: Checklist ① Application for Admission <Form 1>

□ ② Personal History of Japanese Language Study <Form 1-2> □ ③ Study Plan in Okinawa <Form 1-3> □ ④ Essay <Form 2-1> □ ⑤ Independent Study or Independent Research <Form 2-2> □ ⑥ Application Procedure for the JASSO Scholarship <Form 3-1> □ ⑦ Declaration of Support <Form 3-2> □ ⑧ Certificate of Enrollment of the Applicant for Student Exchange Support Program <Form 3-3> □ ⑨ Health Declaration Form <Form4>                       □ ⑩ Application for Certificate of Eligibility □ ⑪ Letter of Recommendation (in English or Japanese) □ ⑫ Academic Transcript (issued by the applicant’s home institution, in English or Japanese) □ ⑬ Certificate of Enrollment (issued by the applicant’s home institution, in English or Japanese) □ ⑭ An official score certificate from TOEFL or TOEIC □ ⑮ 4 identical photographs (upper half of the body, plain background, 3 cm×4cm, Unclear photos and digital files will not be accepted; the applicant’s name □ must be written on the back of each photo.)

This application package must be submitted to the International Student Office of the applicant’s home institution. Please do not send it directly to the University of the Ryukyus. Applications should reach the University of the Ryukyus at the following address no later than March 16th, 2012 International Student Center University of the Ryukyus 1 Senbaru, Nishihara, Okinawa 903-0213 Japan Phone: 81-98-895-8096 Fax: 81-98-895-8102
Please type all entries, handwritten applications will not be accepted. <Form 1> University of the Ryukyus Short-Term Student Exchange

Program (URSEP)
IdentificationPh otograph (3cmx4cm)
*Taken within past 6 months the

APPLICATION FOR ADMISSION

(1) Name (Indicate the full legal name that appears in your passport.) Kurniawan (last) Ardianto (middle)

(first)

(In the Roman alphabet) Kurniawan (last) Ardianto (first) (middle)

(In your native language script) Kurniawan (last) Ardianto (first) (middle)

(2) Present address: Jln. Jomblang Perbalan No.5 Rt.7 Rw.1 Kelurahan Candi, Kecamatan Candisari, City: Semarang, Province: Central Java, Indonesia Phone number: +628562754533 Fax number:

E-mail: ardi_fpik_undip@yahoo.co.id

(3) Permanent address: . Jomblang Perbalan No.5 Rt.7 Rw.1 Kelurahan Candi Kecamatan Candisari, City: Semarang, Province: Central Java, Indonesia Phone number: +62248456987

(4) Emergency contact: (Permanent address と同じ場合は記入不要 ) Name: Titik Setyawati Address: Jln. Jomblang Perbalan No.5 Rt.7 Rw.1 Kelurahan Candi, KecamatanCandisari, Semarang, Central Java, Indonesia Phone number: +6281390583987 E-mail: tiyanadi_stemba@yahoo.co.id Fax number:

(5) Sex:

□Male □Female  
Single

(6) Marital status:  □

□Married
08 (month) 14 (day)

(7) Date of birth : 1990 (year) (8) (9) Nationality: Indonesia

Home institution: Diponegoro University Faculty: Fisheries and Marine Science Major/Concentration: Fisheries ( AquaCulture) Year of Enrollment: 2008

Year of Study: (As of Oct 1, 2012) Undergraduate Master’s program Doctoral program

□ □ □

2nd 1st 1st

□ □ □

3rd

□ □

4th year

2nd year 2nd 3rd year

(10) Educational background (beginning with the last high school you attended)

      Institution High School College/ University

Name of institution SMA Negeri 5 Semarang Diponegoro University

Major field of study Ipa (Science) AquaCulture

Period of enrollment (years) 2005 - 2008 2008 -

(11) Desired period of study (one or two semesters)

□ □

2012 Fall Semester only (October 2012 - March 2013) 2012 Fall Semester and 2013 Spring Semester (October 2012 - August

2013) (12) Passport information: Passport number: A 1776715 Date of issue: 19 Dec 2011 Issuing authority: Semarang Immigration Date of expiration: 19 Dec 2016

I certify that all the information on this form and in the accompanying documents is complete and accurate to the best of my knowledge, and if admitted, I agree to comply with the rules and regulations of the University of the Ryukyus.

Signature: Date : 2012 (year) 02 (month) 01 (day)

<Form 1-2>

Personal History of Japanese Language Study

Knowledge of Other Languages
English Japanese (Others) Excellent ・ Good ・ Fair  Excellent・Good・Fair・None Excellent ・ Good ・ Fair
TOEFL score: 537 JPLT level: 5

※If you have studied the Japanese language, please fill in the information below:
Duration of Study No. of class hours per week Title and publisher of textbooks used

High school

2005-2008

2 Hours per week

Minna no nihonggo

University

2008

Other

※Have you visited Japan before? {  Yes   /   No  } If yes, please provide details of your visit and the purpose of your travel to Japan.
Year How long Purpose Where in Japan

<Form 1-3>

Study Plan in Okinawa
◆The main objective of your particpation in this program: Please number the following according to your priorities, with 1 being the most important. If the options are not applicable, please leave them blank. ( )I want to improve my knowledge of my area of specialization in English ( ) I want to learn more about Japan ( ) I want to experience life in Japan

( ) I want to improve my Japanese language ability

◆The objective of your intention to take Japanese lessons: Number the following according to your priorities. ( ) I want to be able to talk with Japanese friends entirely in Japanese (   ) I want to learn 2000 kanji characters and will be able to read a Japanese newspaper ( ) I want to be able to write a description of myself in Japanese ( )I want to improve my listening ability and be able to understand Japanese TV programs ( ) Other objectives, if any

◆Please list the top three subjects that you wish to study. (               ) (               ) (               )

◆Why did you choose Okinawa? Please check the box if you agree with the corresponding statement. □ Because I am interested in Okinawan culture. □ Because I am interested in the political issues of Okinawa. □ Because I like warm weather. □ Because I like marine sports. □ Because I am interested in the contents of URSEP. □ Other reasons ( )

◆If you plan to submit a report or thesis for this program, i.e. you intend to register for independent research (worth 2 credits per semester), please provide details below: ①The title of your research:                       ② Your academic adviser at your university:  ③ Have you obtained a recommendation from your academic adviser?   { Yes / No }     ④ Have you confirmed that the credits will be accepted by your university? { Yes / No } 

Please type all entries, handwritten applications will not be accepted. <Form 2-1>

E S S A Y
Full Nam e: M ajor or subject of concentrationyour hom e institution: at

(1) Briefly sum m arize your m otivation for applying to URSEP .

(2) Briefly describe your plans for study after returning to your hom e institution on the com pletion of URSEP.

Please type all entries, handwritten applications will not be accepted. <Form 2-2>

University of the Ryukyus Short-Term Student Exchange

Program

(URSEP) Independent Study or Independent Research
Full Name: Home Institution: Major or subject of concentration at your institution: Do you intend to conduct independent research? □Yes, I will conduct independent research □in the Fall semester   □ in the Spring semester. □No If yes, please fill in the information below. (1) Title of your independent study or research:

(2) Describe what you would like to do in your independent study or research.

(3) Name of advisor at the University of the Ryukyus that I would like to have as the supervisor of my research: I permit (student’s name) research. Name of home institution advisor: to conduct independent

Signature of advisor:

Date:

<Form 3-1>

Application procedure for applicants who would like to participate in this program at their own expense in the event that they do not receive a JASSO scholarship

Do you wish to participate in the STRP program even without a JASSO scholarship?

Yes

□ No

You must submit the "Declaration of Support" on the next page.
* Living expenses in Okinawa are relatively low compared to those of other cities in mainland Japan. Monthly living expenses including accommodation are expected to cost between \50,000 and \80,000 a month.

Note: (1) Regardless of whether they receive a JASSO scholarship or not, students from Universities that have a mutual tuition waiver agreement or are partner universities of U.S. UMAP are exempt from entrance examination fees, admission fees and tuition fees. (2) Your selection as a candidate for a JASSO scholarship will not be affected even if you indicate a willingness to participate in the program without a scholarship. (3) The number of JASSO recipients is decreasing every year. It is necessary for you

to submit the “Declaration of Support” form if you would like to participate in this program regardless of whether you are selected for a JASSO scholarship. Even with the submission of the declaration form, your chances of being selected as a recipient of a JASSO scholarship is the same as those who do not wish to participate in the STRP program without a scholarship.
(4) The “Declaration of Support” form has to be submitted at the same time with the rest of your application documents. You will not be allowed to submit the declaration form separately at a later time as there will be insufficient time to process your application. If you do not submit the declaration form, you may be denied the opportunity to participate in this program at your own expense in the event that you fail to receive a JASSO scholarship.

<Form 3-2> Declaration of Support (留学経費支弁保証書) 氏   名: Name of Applicant:                               国   籍: Nationality:                                   在籍大学名: Home Institution:                                 上記の者が琉球大学に交換留学生として留学するにあたり、 必要な経費を負担すること を保証します。 The supporter shown below guarantees the necessary expenses for the person shown above in the event he/she is admitted to study as an exchange student at the University of the Ryukyus. Supporter (経費支弁者) 氏   名: Name of Supporter:                 Signature: 住   所:  Address:   職業(勤務先の名称):  Occupation (Name of Employer):   年間収入:          円 Annual Income: ¥ 月平均支弁額(円): The amount of support per month that can be provided (Average): ¥ 申請人との関係: Relationship to the Applicant:                           (電話) Tel:              (電話) Tel:

* If the supporter is not a relative of the applicant, he/she must submit a letter

explaining why he/she is willing to support the applicant. Documents that prove the financial capabilities of the supporter, such as a copy of bank statements, certificates of income and so on must also be provided.