Form 4

Date: 2020 December 02　

　　　

Application Form for Issuance of Certificate of Scholarship

To: Japan International Cooperation Center

Name: Kuruppu Arachchi, Chandra Wasantha Kumara

JDS No.:B0012020LKA007
Country: Sri Lanka
University: International University Of Japan
Signature:

I hereby request documents proving my status as a JDS Fellow who receives a scholarship from JICE
(Certificate of Scholarship and Financial Statement) for the following reasons:

To be submitted to : ( ) Immigration Bureau in Tokyo 　　　 　

( ) Embassy/Consulate General of Japan in 　
　　　　　　　　　　　　　　　　　　　 (city / country)
( ) Other 　　　

Reason for application (Please tick the appropriate bracket "[ ]" and fill in the blanks):

[ ] For family member(s) to stay with me in Japan (to obtain VISA for them)
【Information about the family members】
1.
Name Ranagala Gamage, Dilini Dinusha
Sex Female
Date of Birth 1987 March 30
Relationship Wife
2.
Name Kuruppu Arachchi, prabashwara vishwajith
Sex Male
Date of Birth 2011 January 17
Relationship son
3.
Name
Sex
Date of Birth
Relationship
4.
Name
Sex
Date of Birth
 Relationship
【Length of stay and status of eligibility】
Date of Arrival : 2021 February 05
Date of Departure : 2022 August 20
Status of Eligibility :（　　）Dependent （　　）Short-Term

[ ] Others
【Please clarify the reason including the expected period of stay if you use the certificate for
the application for VISA of the third country】