Application for Individual Assessment of Admission Eligibility

Tokyo Institute of Technology International Graduate Program ( A) Commencing in September 2022

*T h e f orm is on ly for appl icant s re ques ting speci al adm iss ions consider ation based on the eli gibil ity condit
A (4)ion
, A(5) , (A (3), i f ap pl icab l e)
for the Master's Program or B(3) for the Doctoral Program, as set forth in Section 3, “Eligibility” in the application guide.

To the president of Tokyo Institute of Technology

This is to certify that I wish to apply for the Tokyo Institute of Technology’s International Graduate Program (A)
under condition (4), (5) ((3), if applicable) of "3. Eligibility" in Application Guide, and, having attached the
required documents, request
Individual Assessment for eligibility to apply.

1.Name in full in Roman block capitals 2.Sex

□Male
， □Female
(Family name) (First name) (Middle name) 　

3.Date of birth (Year／Month／Day)

／ ／
( Year ／Month ／Day Age(as of September 30, 2022))

　　 4.Program（Check your intended program）

□Master' Program　　□Doctoral Program

Present Tel ( )
Address Email

Previous
education
Graduate / dropped out in (month/year)
Date Work experience (describe experience related to your research, development, etc. Remarks
(year/month/day) activities) (official announcer, etc)

Date
Activities in academic societies, etc. Remarks
(year/month/day)
Instructions: The information above should be up to the present.