APPLICATION FOR JAPANE.

SE GOVERNMENT (MEXT) SCHOLARSHIP

Young Leaders' Program Student for 2023 (Healthcare Administration)

(-,.:,,:7' • !J-Y-:X · 7'c :1'7Affi$1£) (~-ff~::i-A)

I NS TR UC T I ON S (12}..1:.ll)i'.±;I:)
1. The application should be tYl)ft?'ittan if possible, or neatly handwritten in block letters. <"'•1;::EJ,..-t!>~t.)
2. Number-s should be in Arabic figures. (lk*liJJJ!lllt*~Jlh'-o::c.)
3. Year should be written in the Anno Domini system. (~-!tliT....:.tl§llfc-t"-o::c.)
4. Proper nouns should be written in fu! I, and not be abbreviated. (fi:fr~PlliT~·c:IE>'tt.t~f!;c L., -l;Hn&t...t.ci ,:: c.)
*Personal data entered in this application will only be used for scholarship selection purposes, and contact
information such as e-mail addresses will only be used for forming related hwaan networks after the student returns
home and for sending of information by the Japanese Government.
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(Sex}
1. ~ame in Full in Your ~ative Language OMale (~)
(~,t, (13 IJlll)} OFemale (:t.)
(Fam1 I y name/surname)' {F1rst namt-} (Q1ddle name)

In Roman Block Capital Letters (if written in the passport, follow that form) (Marital Status)
,,;r.:r- 1-~nc~·~-ow.~11, ~n1:~b-1t-o::cl

.
(c-"?~, OSingle (* .. )
DMarried(ft
)

(Family name/surname) (First name) (Middle name)

2. Xat iona l i t y 2- 2. Possessinn of Japanese Xat i ona l i t y OYes, I have (Ii~')

(Ill fl) (13;;$;:IJlfta-"R"To~) O~o. I don' t have (PP;t)

3. Date of Birth(~~Jl 13)

19
Year (~) Month rn) Day (El) Age: as of October J, 2023
(2023 q;_ 10 Jl I El ~(:ECTJ~·)
Paste your passport photograph
4. Conferred Degree (Please check):
[ ] Bachelor Degree [ J Master' s Degree ] Doctoral Degree taken within the past 6 months.
(l!'i~ L.t:.ff ~±/.±/1'±) Write your name and nationality
Possessing License of Medical Profession (Please check): in block letters on the back of
] Medical Doctor I J Pharmacist J Dentist ] Midwife [ :-iurse the photo.
[ J Others [Specify:
(l'Jr;ff-t o 1ti!F i!illli/JI~J~/·fll!iiii! WJiHli/:l'IICili/ -{- q:,ft!!.)
(~JI ( 6 x 4Cll))
5. Present Status: with the name of the current work place
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Present Status (Workplace/ Position)

Current Work Address

Te 1 ephone number Facsimile number E-mai 1 address

6. Present Home Address. Telephone :',umber, Facsimile Xumber , and E-mai 1 Address
(~itffl, •lli1t.ft. 77 :;,:7;<.1i.ft&V:E:i--1v7 ;:i.,,;,.)
Address

If the above present home address will be changed at the tiine of leaving from your country, please specify the
changed address below. (tl El a.yq:,f1mt•1:.Jc~i:Eml'J•toi:J!:l:.t.t o:11-8-nl•:iE L. -C~ 'olilHl'li, rYcl:.~J,.. +s ; c,l

I
 Telephone \umber Facsimile \umber E--mai I Address

• If possible, write an E-mail address where you can be contacted for periods that include the time before you come to
Japan, your stay in Japan and the period after you return home.
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1. Field of study specialized in the past (Describe as detailed and concrete as possible.)
(i(j4H:q t, n-.•l"~Jf ("t'! -?i ~It Al*&!Ji::u.u:• < .:. l l c.

8. Educational Background ('1:~)

Diploma or Degree Awarded.

\ame and Address of School MO\Tll and YEAR Period of schooling Major Subject, Skipped
of Entrance and You llave Attended
Yeats and Levels
Completion
<*t2~&amH.!I!!> (A~&t1$.~}l) (tl'$~11:) (~···- q~I'!, flt
t,'&11.)~Dt)

\ame From years

Ele1111ntlll'Y Education (fflf,) (.7'.~) (~)
C~4HtW>
Elementary School Location To and
(,J,ffl) (ml'ftt!!> ($Ill months
(}l)

\ame From years

Secondary Education (ffl~) (A~) (~)
('l'•tt•)
Lower Secondary School Location To and
(q,*) (f}fH.lt!!) ($1l) months
(JO

\ame From years

(ffl,g) (.7'.*) (~)

Upper Secondary School •-1

(i*it2) Location To and
(p)iffill!l ($Jl) 1DOnthS
(}l)

Xame From years

Hiaher Education (.7'.$)
(al•••> (~~~) (~)

Undergraduate Level Location To and

(:j;;~) (ffitfil!!) ($lU months
(}J)

\ame From years

(~f,) (A~) (~)
Graduate Level
(;k~ll.t,) Local ion To and
(fflffffll) (zjS..) months
(}l)

Total years of schooling mentioned above years

(£1.J:.!-il. \...f::i:$t2il!!cffif$~1t) (~)

*ff the blank spaces above are not sufficient for information required, please attach a separate sheet. In such case,
please stipulate that the information is on a separate page.
( (it:> ..1:.•1:•~ ~.nt.:Hl-%1:11. !M~t.:SJJ{jli;i:tc..7'. vc~-t-o.:. c.
-'fl1)~l±, 81J¥1:tckto 'ii'a-- J:ic$1t•1:1JJtc-ro:. t.
Xot es : 1. Exclude kindergarten education or nursery school education. (~ftlll ·~Wmil!!c'llfli1."£hf.t~'.)
2. Preparatory education for university admission is included in upper secondary school. (\ 'b~o rj;:1,:'Hlft'lfJ lii9it2
1:1i1J:no.>
3. leaving qua l r f i car i on, indicate this in the blank with •-l. (ifi1J
If the applicant possesses a high school-equivalent
ffl$1lfi.llW~a--'lr vc~ '0~1:1±. -t"-''lia-*-1 •i:tc.7'.-t-o:. t. >
4. Any school years or levels skipped should be indicated in the fifth column (Diploma or Degree awarded. Major Subject,
Skipped Years and Levels). (Example: Graduated high school in two years, etc.)
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5. If you attended multiple schools at the sane level of education due to moving house or readraission to university,
then write the schools in the sanie column and include the number of years of study and current status for each
school. (f}:J8C1J8fi~::k$C1Jl'JJ..~~~JIE1ll:. ll!lft.Rf:i~Wll:C1J~l:f:UIL-n'~~li. Ii:! i.:11::Wll:<7.)fflC1Jtff1!-lc
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6. Calculate and write the total number of years studied based on duration as a student. (including extended l eave such
as summer vacation) (-~"f.!l!k.g.ftlii':Efl1Qlllll~lll:liL. lc.J..-r-?i:.I::. (~1Qll*1111,~~,5))

* Submission of typed curriculWI vitae is required.

Please do not fail to attach curriculum. vitae with detailed infoI'll8tion in regard to
your job/education history.
In your curriculum vitae, please make sure to describe all your job/educational history
without making any gap years.

9. Employment Record. Begin with the most recent e11ploy11ent. (a~)

~ame and address of or~nization Period of em~oyment Division/Section Position Type of •ark
<IJM!/t&vr~f:E l (Ir~· ) (W,t,J (~at) ceMP'l~l

From
To

From
To

10. State the titles or subjects of books or papers (including graduation thesis authored by applicant), if any, with the naae

<••·
and address of publisher and the date of publication. Abstract of your papers should be attached.
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11. Extracurricular and Regional Activities

(1191-i'!IIJX l"iUti~ ~ 11)ffl:fJJ)
F.xtracurricular and Regional Activities Period
(ll?l-l!~XliJi!!~""t'C1Jl!fJJ) 001111!)

12. Japane~e Language Proficiency: F.valuate your level and fill in with an X where appropriate in the follo•ing blanks.
( a ;t;:Htftl5h 'i' 13 i:.IHfiC1J ? ;t, ~ ~•,: x 1:11-!:-fe.A-t {> :. I:: )
Excel lent Good Poor
(fl) (Jl) (~PJ)
Reading
( IJ!trtti:1J)
ll'riting
<*<AMl
Speaking
(g-r~1Jl

3
 •

13. Foreign Language Proficiency: Evaluate your level and f i l I in with an X where appropriate in the following blanks. About
English, report your score of TOEFL or IELTS.
(?1-ll!HttfJa:- ~ Effflji1)? ;t, u~•1: x l=flH~J-.:t"-o .= I::. t:.~ i.. ~nH:--:i~ '-Cl:l:., TOEFL Xii !El.TS i1)7. :::r 7 t-~.A T~ .= c.)

Excel lent Good Poor

(Wl (lit) (:faJ)
English
(~ff)
French
({L.ff)
German
(liff)
Spanish
(Nffl

Score of TOEFL Score of IELTS

(TOEFL 11).A :::r 7) (!El.TS <l).A::, 7)
OR

14. Person to be notified in applicant" s home country in case of emergency:

( ll~e1.>llite1.>fHle1.>il*&~)
i) \ame in full:
(a:,t)
n) Address; with telephone number. facsimile nur,ber, E-mail address
(i1m : •m•~- 7 7::, 7 ;,.tf~JUiE .,<-,1,,7 !-' VA a-JcJ...O) .=I::,)

iii) Occupation:
(. 11)
iv) Relationship:
(*A/::<l)IIIH~)

l understand and accept all the matters stated in the Application Guidelines for Japanese Government (~EXT) Scholarship for 2023
and hereby apply for this scholarship.
(t/.li2023:!Jc/lf3::$:U (~-'31-~) ~'.'j'::~ii'.'j'::1cJJ•tPll:Ett~nn,o•lJa-T"-C7ML--Clflftl-"i.T.)

Date of Application:
(lflft:!JcJJ a>

Applicant's Signature:
(Jflft~V,t)

Applicant's \ame
(in Roman Block Capitals)
(Jflft~a:!6)

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