English Research Observation Form

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English Research Observation Form Powered By Docstoc
					                                                                                                                              Photo
                                      Tohoku University                                                                Paste your photo
                                                                                                                       (4cm×3cm) taken
                        Application for Industrialised Countries Instrument                                            within the past 6
                         Education Cooperation Programme (ICI ECP)                                                     months.
                                                                                                                       Write your name
                                                                                                                       and nationality in
                                                                                                                       block letters on the
                                                                                                                       back of the photo.
Check the boxes below where applicable.
APPLICANT INFORMATION
NAME AS SHOWN ON YOUR PASSPORT
Family                     First                                                               Middle



                                        Date of birth (year / month /
Nationality (stated in your passport)                                 Age                      Gender                  Marital status
                                        date)
                                                                                                   Male                    Single
                                                 /       /
                                                                                                   Female                  Married
CURRENT HOME ADDRESS (number, street, Apt. No.)



(city, state)                           (country)                                              Postal code



Telephone number                                                                               E-mail address
(country)    - (city)        - (area)   -(number)
                                                                  Home        Mobile
Passport number                         Expiration date (year / month / date)                  Confirm E-mail address
                                             /       /

EMERGENCY CONTACT
Name of parent(s), guardian(s)                                            Relationship with applicant



Address (number, street, Apt. No.)



(city, state)                           (country)                                              Postal code



Telephone number                                                                               E-mail address
(country)    - (city)        - (area)   -(number)
                                                                        □Home □ Mobile
HOME UNIVERSITY
University name                                                           School



Department                              Current category at home university

                                            Sophomore          Junior         Senior        Master        ( 1st or 2nd year ) course

                                        Expected grade at home university when you start studying at Tohoku University.

                                            Junior             Senior         Master      ( 1st or 2nd year), or Doctor course

                                        Expected date of graduation from home university (Note: Applicants must still be a degree
Date of entrance into home university
                                        candidate at home university when completing ICI ECP program)

(year)             (month)              (year)                                  (month)




                                                             1 / (3 )
                 Name                                        Home University


ACADEMIC BACKGROUND
High school name                                Major                           City                                 Country



                                                Date of entrance (year/month)   Date of graduation (year/month)      Diploma/certificate

                                                         /                             /

(if you have others)                            Major                           City                                 Country



                                                Date of entrance (year/month)   Date of graduation (year/month)      Diploma/certificate

                                                         /                             /

LANGUAGE PROFICIENCY
                           Native or equivalent

ENGLISH                    Would be able to catch up classes conducted in English

                       TOEFL Score (if any) :

                           Native or equivalent

                           Would be able to catch up classes conducted in Japanese

JAPANESE                   Would be able to have conversations needed in daily life
                           Less than above

                       Japanese Proficiency Test Score (if any) :

HEALTH STATUS
In view of your health history, is it your observation that your health status is adequate to pursue studies in Japan?

                                                                                             Yes        No

FAMILY BACKGROUND
Name                   Relationship             Age                             Occupation         Address


Name                   Relationship             Age                             Occupation         Address


Name                   Relationship             Age                             Occupation         Address


Name                   Relationship             Age                             Occupation         Address


REQUIRED MATERIALS WITH THIS APPLICATION FORM
Check the boxes to make sure the following required materials have been attached with this application form.

   Letter of recommendation from home university, which includes the view of physical conditions of the applicant.

   Certificate of enrollment at home university
   Academic transcript at home university
   Certificate of Health

   Statement of purpose including research plan of “Individual Research Training in Lab (IRTLab)” (one page)
   Four photographs printed on photo paper (4cm by 3 cm)

   Photocopy of passport identification page (page with the applicant’s photo and name)
   Application for Certificate of Eligibility




                                                                   2 / (3 )
                 Name                              Home University


STUDY PLAN at TOHOKU UNIVERSITY
DURATION OF STAY
The ICI ECP program basically starts from October or April except in special cases. Also, applicants who would like to finish the
program in a month other than the month below should contact the Student Exchange Division at Tohoku University in advance
through the exchange student advisor at their home university.

    Spring semester (from April to September)                                 Fall semester (from October to March)


RESEARCH PLAN FOR “Individual Research Training in Lab,” which is the core course of ICI ECP program (Your academic
advisor is to be matched with this plan. Applicants who do not fill out this section cannot be reviewed for application procedure.)
Research Field (indicate specific research groups that you would like to join)


Summary of statement of purpose in 200 to 300 words (what you would like to research and your goal)




Other fields of interest for “Individual Research Training in Lab (IRTLab)”
1

2

COURSES OF INTEREST FOR STUDIES AT ICI ECP PROGRAM (Except for “Japanese” and “IRTLab”)
Fall Semester                                       Spring Semester




SIGNATURE OF APPLICANT
I hereby declare that all statements given in this form are complete and true.
Signature                                                             Date (year / month / date)

                                                                                  /        /

Name in Japanese Katakana
(if possible)
For Chinese, Taiwanees and Korean students:
                                                                      NB: If you are Korean, please write your household
Please write your name in Chinese characters in handwriting.
                                                                      registered name in Chinese characters. If it is not registered
                                                                      in Chinese characters, please write in Japanese Katakana.
                                                                      This is important for application for Certificate of Eligibility.

SIGNATURE ON BEHALF OF HOME UNIVERSITY
I hereby certify that this student has been selected by his/her home university to participate in the exchange program with Tohoku
University and that his/her application is complete. Furthermore, I certify that the student’s proposed study plan is approved and
that the courses applied for will be recognized.
Coordinator’s name                                                   Title



Signature                                                             Date (year / month / date)

                                                                                  /        /

E-mail address                          Telephone                                              Fax




                                                          3 / (3 )

				
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