APPLICATION FORM FOR HITACHI SCHOLARSHIP
Name:
(Family Name) (First Name) (Middle Name)
Photo taken recently without hat 3cm x 4cm Nationality:
Photo taken recently
without hat
3cm x 4cm
Date of Birth: Age:
(Year) (Month) (Date)
Sex (circle): Male or Female
Marital Status (circle): Single or Married
Current Title/Position in University:
Mailing Address:
Permanent Address:
TEL:
(Office) (Mobile Phone)
FAX: E-Mail Address:
(Office)
Contact in case of Emergency
Name & Relation:
TEL/FAX/E-Mail:
Proposal on School/Course/Period/Host Scientist
Intended Graduate School
Department:
Major:
Course (circle): Master and/or Ph.D.
Period
From To
No. of Years
Japanese Host Scientist
Title or Position:
Reason for Selection of Host Scientist/Graduate School
Supervisor in Home University
Educational Background (from primary school)
Name of School
Place/Country
(YY/MM – YY/MM)
Degree
Financed by
–
Honors Awarded:
English Language Ability
1. Please evaluate your English language ability by Excellent, Good, Fair or Poor.
Reading
Writing
Hearing
Speaking
Ability
2. Please describe how long and where you have studied English.
Period of Study:
Location and Institute:
3. Please describe your score if you have taken the Test of English as a Foreign Language (TOEFL) or similar test.
Score:
When:
(Year) (Month)
Record of Study of Japanese Language, if any
Institute
Location
Period of Study
1
2
Record of Past Entry into / Stay in Japan
No. of Times
Physical Condition (circle)
Excellent Good Fair Poor
Military Service (circle)
Completed Not yet completed No requirement
Work Experience
School/Institution
(Location)
Position
Type of Work
