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Application for Short-Term International Joint Education Program

For Environment and Energy


In Graduate School of Science and Technology (GSST),
Kumamoto University

Paste your passport

photograph taken within the


past- 6 months.

Graduate School of Science and Technology, Kumamoto University

Write your name and

Kurokami 2-39-1, Kumamoto 860-8555 JAPAN

nationality in block letters


on the back of the photo.

Tel: +81-96-342-3020 Fax: +81-96-342-3010

(43

E-mail: ask-gsst@gpo.kumamoto-u.ac.jp

1. Name (Please spell it exactly as it appears in your passport):


In your native language
Last

In roman block capitals


Last

First

2. Nationality:

First

Middle


Middle

Gender:

Male

Female

3. Date of birth:
/ / /
Month

Day

Year

Age

4. Present address (University):

Phone number: Fax number:



E-mail address:
5. Present address (Home):

Phone number:
Fax number:
E-mail address:

6. Present Status
University/Institution:
Department:
Year in Your School:
Application for Short-Term International Joint Education Program for Environment & Energy, GSST, Kumamoto University

Masters Course
Doctoral Course

First

year
First year

Second

year
Second year Third year

7. Expected Graduation Date:

8. Academic history:
Name of University/Institution

Location

Period of

(city, country)

Numb

Attendance

er of

Month / Year

Years

Elementary Education / Name of elementary school

years

Secondary Education / Name of junior high school


years

Upper secondary / Name of high school


years

Higher Education / Name of University (Undergraduate)


years

Name of University (Master's Course)


years

Name of University (Doctorate Course)


years

Total Years of Education

years

9. Job experience:
Name of Workplace

Location

Job Tenure
Month / Year

1.
2.
3.
4.
5.

10. Language proficiency:


Evaluate your abilities by writing the word "excellent," "good," or "poor" where appropriate
in the following blanks.
Speaking
Listening
Reading
Writing
Japanese
English
Other (

Application for Short-Term International Joint Education Program for Environment & Energy, GSST, Kumamoto University

11. Selection of your course (select one):


A: One Year Course, October 2010 September 2011 (12 months)
B: Fall Semester Course, October 2010 March 2011 (6 months)
12. Selection of your research area (select one):
1. Environment
2. Energy
3. Environment & Energy
13. Prospective supervisor at GSST, if already decided:
Name
Department
14. Appointment of other scholarship
Indicate whether you will receive other scholarship while you receive JASSO scholarship.
Yes
Name of scholarship:
Total monthly amount:
No
15. Do you wish to stay at the International House (i.e. Kumamoto University
dormitory)?
Yes
No
16. Person(s) to contact in case of emergency:
Name:

Address:

Phone Number:
E-mail Address:

Fax Number:

Relationship to you:

Signature
I certify that all the information provided on this form and in the accompanying documents is
complete and accurate to the best of my knowledge.
Date :

Signature:

Application for Short-Term International Joint Education Program for Environment & Energy, GSST, Kumamoto University

Describe your current research at your university, your academic objectives and study plan at Kumamoto
University as detailed and concretely as possible. Additional sheets of paper may be attached if necessary.

Current research at your university:

Academic objectives and study plan at Kumamoto University:

Application for Short-Term International Joint Education Program for Environment & Energy, GSST, Kumamoto University

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