&it (Forml 1/3)

Application Form for TAKARAZUKA UNIVERSITY of MEDICAL and HEALTH Japanese Language Program

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The applicant musi personally conpleie this application, in block letters.

2 trit, E(tl*6+roaBD'r"SlL(</j3ri \.
Fill in the appropriate box ( lYes, lNo ).
5E Photo
(4cnx 3cm)
3 FormltgSqi1tr, \q H rl&16Htt, E!tEt:a.l.Lr</j3u \, Rfi3IJ E
Ifnecessary, please use the attachment io complete Fom l. hr-qH.]EE,,L+q
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Please atrx a coior photo

frg=*Z Intended start of study taken within the last 3

2020 +E lf 6,l.+(48) IF=-;< I year.oursp, Fom Apr.

,ixrl<-l-iED l:-Cy'.L(ftU \. Name as shorvn in passporr.

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tr E vate IAFemde
3. ELfE# Maritatstatus

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single

4. E+F A 2000 +6 E 15E i5.ffi*

8, E'Efr Present AddresstElo)&fr permanent Address in Home Country

TPUR METROPOLITAN CITY WARD NO. 11, CHITWAN, NEPAL

lTell [Mobilel 09zz-98r 1224763 [E-maitl

9. *@D(ifr Permanent Address in Home Country xtes.Iq/r5€6ileilL<<t:51, \"
fill in the present address if it differs llom home countrv address above.

HARATPUR METROPOLITAN CITY WARD NO. 1I, CHITWAN, NEPAL

(Tell lMobilel 0977-9811224?63 [e-maill

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Dare or$. ht6d enhr($y/mm/dd) Ddc ordep.ature ($y/mh/dd)

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Kegaroma yorr nrstorv
or Certrflcate orEliEibilitv F;Ft: &st E 6!(+e4*)
(COE) orvisa application, Plac. or@plication
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 &* (Forml 2/3)

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Have you ever been prosecuted tor any yescriminat acts in Japan or etsryhere? No
13. i6*or&frt.-)u\-a (2)'i6*l.t*ffilxtrHE6+t.t6HErr&D*fr'" D H r*
Past criminal record you
Have deported or
ever been to depad fi.on yes
ordered Japan? No
(3) -lE!+t:-L.Eif ElrrBE6tr,trr,/.:l n\bD*t;h'. E€ I*
Have you ever been denied entry inio a counrry? yes No

14. ?E Educational background

(E) Z'f /l'+&r'bi6+Ltl.{ro+&?if, L<<fl 6r,\.

2Ol2 +3 A

++& BMMTPUR, CHITWAN,

Junior hish school NEPAI, 2017 +6 y,

2017 +7 A
BHAMTPUR_12,
H++& CHITWAN, NEPAL 2019+BE
Senior hish school

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Bdchelor
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Collese
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u .F*?E Expected to saduate

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tr +*a€ Exp".t"d to "b**
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15. fflE Enplovment recora trAYES r 4..E No

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A
Month
+HHffld)iliffi Explanation of btank period XEEt;6rE u,Io+H fifAn e,6ee . t4)#HJr,iA,nn
Ifyour career has blank period of6 months or more, please erplain what you were doing
in this period oftime.
Regd. No.: 1632

pnrnllll $rc0llDlnY [1l01l$il B0[Rll1l0 $cll001

W
Bharatpur-1 2, Chitwan, Nepal
Estd: 2046 B.S. (1989 A.D.) !-*B
ik
@burs $w @efiititnte
S. No.: 639

5fti4 i^ t& cut4*tfrar "l/WAa svsllvl]ITq LAM-A

oanl@usfrret.at "Wlrn'Li F'.Al END P,A LAMA
uoa o Aana.fide otudenl altfria ocfronL, ohce-2079-B'S' .fiblS$.pa.roen

tfie &rnuaL €.qaminatian al Qla.ta lE undu. Sc*ncelnaygenent Su2anl

fteUettJvatisral€aominatiaru Aaatt^d."4repatintfrpqcadcmicU*o"L-9lG-n"5"

(-2AL9 s4.D.) qrrd ouon"d---2:Lq Cff?Aldh,i^asn.

gbl Sg &cana a gotd n orul cfrawdo t.

J WiAh friml@,etcttr 0utces6 h fri,r lfrV$adsnic catpa,..

Dateof Birth: -03- Ol

B.s.2O5+ NEB Registration No.:
-183E q7263
A.D.2ooo-o6-L5 NEB symbolNo.: n 835030 I 2
Dateof rssue: 2O76'07'07 A'S' xu 93502012
,t,^I
ii;,{*, Verified by
 @ 1056-523122, 57A877 , 52a825

A
Reg.No" 1632

PRENANA SECONDARY ENGLISH BOAMDING SGHOOT

\Wi
\wZ
Bhorotpur-1 2, Chitwon, NePol
Estd: 2!46 B.S. (1989 A.D.)
28th Nov, 2019
M. i/o.: Itgl0to,oLo

Letter of Clarification
To Whom It May Concern
This is to certify that Miss Sushmita Lama was the student of this school from 2Ol7 A.D.to 2019 A.D.
under the faculty of Management. She passed her final examination in 2019 A.D. with CGPA (2.14).
Her date of birth according to school record is 2057103101 B.S. (2000/06i l5 A.D.).

Regarding the academic document of Miss Sushmita Lama, on the Character Certificate issued by the
school where school's name and address are printed as PRERANA SECONDARY ENGLISH
BOARDING SCHOOL Bharatpur-l2, Chitwan, Nepal and the Academic Transcript issued by
NATIONAL DG.MINATIONS BOARD (rlEB) is printed as PRERANA SECONDARY ENGLISH
BOARDING SCHOOL, BHARATPUR 12, CHITWAN also in the officially used school stamp
where school's name and address is written as PRLRANA SECONDARY ENGLISH BOARDING
SCHOOL, CI{ITWAN. Similarly, in the school's letter head where the school name and address is
written as PRIRANA SECONDARY ENGLISH BOARDING SCHOOL Bharatpur-l2, Chitwan,
Nepal. So, we would like to confirm you that the school name and address in the Character Certificate,
Academic Transcript, officially used stamp and letter head seems different but the name and address
remains same.

If you have any queries about all these, please f""t f.." to contact us at any time of school hours
without any hesitation.

Thank you!

=tfi:r*
Mr. Mohan Lama

"ffhl\"iP"t
Reg. No. 1632

PRERANA SECONDARY ENGTISH BOARDING SGHOOT

r- I 2, Chitwqn, Nepol
.s. (r989 A.D.)
6h Jan,2020
Ref- Ata-: lLg | 0 tql O2'D 9ata:

To Whom It May Concern

This is to verifu that the school logos printed on school letter-head and .Character Certificate of Miss
Sushmita L^ma (+2 Level) issued by school are same and original as per the sample ofschool seal and
logos shown hereunder:

Therefore, I hereby declare that the above school seal--and logos are the original and the stamped
documents are true.

If you have any queries about all these, please feel free to contact us at any time of school hours
without any hesitation.

Thank you!

..-tf''::Yl
Mr. Mohan Lama
Princioal
F?riiisisa[
 aRdIIEffi
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c. It
rrag, fua-+q, irte
CITY
Date: 10th Dec,2019

Subiect: Verification of Relationship

To Whom It Mav Concern
This,is to certifr that Miss Sushmita Lama, permanent resident of Bharatpur
Metropolitan City Ward No. 11, Chitwan, Nepal has the following relationship
recognized as per official records. This certificate is verified and issued according
with clause of l2(2) (E-1) of the Local Govemment Operation Act,2074 B.S'
(2017 A.D.).

The photographs of mentioned members are a4ached herewith.

a\
$a(Or
rtd rr-
Miss Sushmita Lama
(Applicant)

\)
c4'

WardGhai
Mr. Rajendra Lama Mrs. Shanta Lama
(Applicant's Father) (Applicant's Mother)

Ph.: 056-526388