APPLICATION FORM TO GRADUATE SCHOLARSHIP PROGRAM

for September 2011 Intake

Faculty of Science and Engineering, Waseda University

Note to Applicant: This application form consists of two pages. Type or print clearly. This
form must be submitted with other necessary documents.

1. Program applied: □ Doctoral program □ Master’s program

2. Department of study applied:
(Please select your desired Department from the list of “Information.”)
Attach a
3. Name: , recent photo-
family 　　 first 　 middle graph here

4. Nationality: 5. Sex: □ male □female

6. Marital status: □single □married

7. Date of birth: 8. Age (as of April 1, 2011):

9. Mailing address (Give address where you are surely contacted until September 2011.
If you plan to move, give present address and future address and show valid period.):

Telephone number : 　　　　　　　　　　　　　

Facsimile number (if available): 　　　　　　　　　　　　
E-mail address : 　　　　　　　　　　　　　

10. Academic record:

Bachelor:
name of institution 　　　 　 location

　
from (Mo. /Yr. ) to (Mo. /Yr. ) 　　　 degree 　　 major field

　
scholastic honors or prizes (if any) 　　　　 class rank/total number of students

Master:
name of institution 　　　 　 location

　
from (Mo. /Yr. ) to (Mo. /Yr. ) 　　　 degree 　　 major field

　
scholastic honors or prizes (if any) 　　　　 class rank/total number of students

Other:

1
 name of institution 　 　 location

　
from (Mo. /Yr. ) to (Mo. /Yr. ) 　　　 degree 　 　 major field

2
11. Employment record (Write employed period, employer’s name, job title and job
description. Start with the most recent employment.):

　　
period 　　　 employer’s name 　　　　　 job title and description

　　

　　

　　

12. Other professional experiences if any:

13. Present status:

14. Field of interest in detail and study plan at Waseda University:

Use separate sheet and attach to this form.

15. Future plan after completion of the program:

16. Name of two persons who write recommendation letter for you. (Two recommendation
letters in specific form should be sent directly to the Faculty.)

(1) 　　
name 　　　 title 　　　　 institution

(2)
name 　　　 title 　　　　 institution

17. List of other graduate schools you are applying to:

　　　

18. Will you surely be able to come to Japan in September 2011?

□ Yes □ No (explain reason.)

19. I certify that I have read all instructions and that information in this application is true and
complete. I understand that misrepresentation may be cause for canceling my admission.
I understand that all credentials and documents I submit become the property of Waseda
University.

　
signature of applicant 　　　 date