2009年度（平成21年度）.doc

Shizuoka University Special Admission for Foreign private students for autumn enrollment 2009 Faculty of Engineering, Overseas Examination Eligibility Check (Application) FormInstructions - The application should be typewritten or use word-processor if possible, or neatly handwritten in block letters. Underline(s) may be deleted. - Numbers should be in Arabic figures. - Year should be written in the Anno Domini system. - Proper nouns should be written in full, and not be abbreviated. - Format should not be changed. - Send this form both in the paper and electric form (PDF format). Please use airmail and e-mail. 1. Name in full (In Roman block capitals) Family name First name Middle name_ Sex: Male Female 2. Nationality_3. Date of birth (Age: as of October 1, 2009) Year Month Day Age 19_4. Present address (In Roman Block)_5. Telephone/Facsimile number & E-mail address Telephone/Facsimile number _ E-mail address _6. Purpose for admission (In Japanese or in English: Be as detailed and concrete as possible.)_7. Field of study specialized (Give priority order 1 to 3) Department of Mechanical Engineering Department of Electrical and Electronic Engineering Department of Materials Science and Chemical Engineering 8. EJU score Examination date and location Date: yy _ mm _ dd _ Location (name of the city): _ Examinees number: _ Scores Mathematics (Course 2): _ Physics: _ Chemistry: _ Japanese as a Foreign Language:_9. JLPT score (in case of examinee) Examination date and location Date: yy _ mm _ dd _ Location (name of the city): _ Examinees number: _ Certificates of Proficiency Level _ with score _10. English score (one of below) TOEIC: _ TOEFL(CBT): _ TOEFL(iBT): _ IELTS: _11. Educational background 1) Elementary Education / Elementary school Name of School: _ Address of School: _ _ Scheduled necessary study years for graduation: _ Year and Month of Entrance yy _ mm _ Year and Month of Completion yy _ mm _ 2) Secondary Education / Lower Secondary school Name of School: _ Address of School: _ _ Scheduled necessary study years for graduation: _ Year and Month of Entrance yy _ mm _ Year and Month of Completion yy _ mm _ 3) Secondary Education / Upper Secondary school Name of School: _ Address of School: _ _ Scheduled necessary study years for graduation: _ Year and Month of Entrance yy _ mm _ Year and Month of Completion yy _ mm _ 4) Higher Education / University or college (if any) Name of School: _ Address of School: _ _ Scheduled necessary study years for graduation: _ Year and Month of Entrance yy _ mm _ Year and Month of Completion yy _ mm _ 5) Japanese Education / Japanese Language school Name of School: _ Address of School: _ _ Scheduled necessary study years for completion ( if scheduled): _ Lectures: _ hours/week Year and Month of Entrance yy _ mm _ Year and Month of Completion yy _ mm _The items below do not affect the result of the examination 12. Person who supports your studying abroad (The information is used only for immigration procedure.) (Name in full, in Roman block capitals) Family name First name Middle name _ _ Age Address: _ _ Relationship: _ Occupation: _ Possible annual amount of support in JPY: _13. Health condition Is your health condition good enough to study in the university? Yes_, N