様式１(Form 1)

KYUSHU UNIVERSITY
FRIENDSHIP SCHOLARSHIP
APPLICATION FORM

INSTRUCTIONS
① Typewritten or handwritten in Roman letters
② Arabic numerals
③ Years in Anno Domini system
④ Proper nouns in full and not abbreviated

PERIOD OF STUDY AT KYUSHU UNIVERSITY (from 3 to 12 months)

From to
Paste a passport-size
(day / month / year) (day/ month / year)
photograph taken
within the last 6
■PERSONAL DATA
months. Write your
1. Name in full, in Roman block capitals name and nationality
， in block letters on
(family name) (first name) (middle name) the back of the
photo.
2. Home University

3．Date of birth etc.

19 / / Male / Female Single / Married
Year Month Day Age

4. Nationality

5. Present address and telephone number, facsimile number or e-mail address

Number and street
City State Zip
Country Telephone / Fax /
E-mail
(Please fill in your most active E-mail address.)

■FINANCIAL SUPPORT
1．Do you have any other scholarship application in mind ? Yes No
- If yes, give details and expected date of result.

2．Have you received a Japanese scholarship before? Yes No

- If yes, give details.

3．Could you study at Kyushu University without a scholarship? Yes No

- If no, give details.
■ACADEMIC DATA

Requisite Year and month Degree

Name and address Period of Major
years of of entrance and if
of school schooling subject
schooling completion applicable
School name yrs
From
Junior /
Secondary High Sch yrs and
to
education Location
/
mos.
Secondary yrs
School name from
school
Senior /
yrs and
High Sch Location to
/
mos.

Univ. name yrs

Higher education from
/
yrs and
Undergraduate level to
Location
/
mos.

Univ. name yrs

Higher education from
/
yrs and
Postgraduate level to
Location
/
mos.

Current school year/grade Total years of schooling years

Expected date of graduation / /

Any research to date e.g. thesis title(s)

please fill in the thesis title(s) or short description of research you have been engaged in to date

Awards / accomplishments
please fill in award(s) if you received any / accomplishment to be mentioned particularly

■EMPLOYMENT RECORD： Begin with most recent employment, if applicable.

Name and address of organization Period of employment Position Type of work

from: /

to: /
from: /

to: /
■RESEARCH PLAN

[Theme of Research in Kyushu University]

Research Plan
[Note] For those who study in Kyushu University NOT as Double Degree Program student this time
In addition to the research plan this time, please include the research plan which you want to conduct when you enroll in Kyushu
University as a degree-seeking student in the future.