邢唷??>? ?????欹?[?餜?_?bjbj  4?pa!\pa!\?D?R R ??***>>>8v?",>#3?NNddd??????????$?????*??@??????dd"?c&c&c&???8d*d?c&??c&c&r?T0d?嬻,栌?????0#30]9m#?]90]9*0?????c& t?i????? %Z???#3????]9?????????R N ?: KOCHI UNIVERSITY OF TECHNOLOGY GRADUATE SCHOOL OF ENGINEERING  Special Scholarship Program (SSP) Application Form for April 2019 IMPORTANT NOTE: Type or write in block letters.* Unclear or incomplete applications will not be considered. 0 00Have you ever applied for SSP before? ?Yes ?No *If your answer is Yes, When ? _____________________Paste a recent photo here( Male ( Female ( Single ( Married  (1) Name _________________________________________________________________ * Write your SURNAME (followed by your first name) in CAPITAL letters here. (2) Nationality _____________________ (3) Date of birth ___________________ (4) Age (at time of enrolment) ________ Year / Month / Day (5) Present occupation (e.g. masters' student, instructor, etc) ________________________________________________0 Name of school or employment at present ________________________________________________ ________ 0000000000000000000*If you are Chinese, write in both English and Chinese (6) Present mailing address ________________________________________________________________________ ______________________ Postal code ____________________Country______________________ Phone ________________________ Fax _________________________ E-mail ______________________________ (7) Permanent address, if different________________________________________________________________________ ______________________ Postal code ____________________Country______________________ Phone ________________________ Fax _________________________ E-mail ______________________________ (8) Refer to the project list for SSP and write your 1st preference project name and project leader. Name of project leaderProject name1st preference If you have a 2nd preference, write it here. Name of project leaderProject name2nd preference (9) Educational background *Please write down all the schools that you were enrolled in, including the schools that you are now registered. School name, city, countryTime of entrance and completion (month/year)Length of schoolingDiploma/degree awarded, major subject(A) Elementary SchoolSchool name City, Country From / to / years and months(B) Lower Secondary SchoolSchool name City, Country From / to / years and months(C) Upper Secondary SchoolSchool name City, Country From / to / years and months(D) Undergraduate LevelSchool name (*If you are Chinese, write down in both English &Chinese) City, Country From / to / years and months(E) Graduate LevelSchool name0(*If you are Chinese, write down in both English &Chinese) City, Country From / to / years and monthsTotal years of schooling described above years* If the space above is not sufficient, please add more space as needed. (10) Employment record (if applicable) beginning with the most recent employment Employer, city, countryPeriod of employment (month/year)PositionType of workEmployer City, Country From / to /Employer City, Country From / to /* If the space above is not sufficient, please add more space as needed. (11) List of publications (State the titles of books or papers, including graduation theses, with the publisher's name and date of publication. Please attach abstracts.) (12) Academic honours and prizes, if any. (13) Language ability other than your native language.0(Check each section to show your language ability) 0 Speaking Academic reading Academic writingBasicBasic daily conversation Discuss academic material BasicIntermediateAdvancedBasic IntermediateAdvancedIntermediate AdvancedIntermediate AdvancedEnglish 00000000000Japanese00000000000Other 00000000000 *If applicable, give the following information: ?Name of English Exam such as TOEFL, IELTS, TOEIC, CET , etc : _________________0Score: ________________ ?Japanese proficiency test level : 0_________________00 (14) If you are applying for another institution s scholarship, or if you have already received another institution s scholarship, please give the name of the scholarship and its term. Scholarship nameTerm of the scholarship   (15) If you are applying to other university, give the details in the space below. (16) Have you ever visited Japan? (No (Yes (Period of stay : From to ) month/year month/year * Purpose of stay (e.g. study at school, internship or work):0 ______________________________________ (17) Have you ever lived abroad? ?No0?Yes (please give the following information) 0000(a) Name of country: (b) Period of stay: From to ) (c) Purpose of stay (e.g. study at school, internship or work): ______________________________________ (18) What is your plan after completing the Doctor s program at KUT? ? Return to your current occupation ? Join Educational / Research Institute in your country ? Work in Business enterprise in your country ? Join Educational / Research Institute in Japan ? Work in Business enterprise in Japan ? Others ( ) (19) Write the names of two persons whom you have requested to write a letter of recommendation. 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Please circle one or more of the following: 1. From KUT's web page 2. Recommendation from your supervisor or university 3. From an alumnus 4. From a KUT Professor 5. At a study abroad event 6. From the Internet (Web page name: ) 7. Other ( ) I understand the following two points: (1) Missing or incomplete required documents will result in the rejection of my application. (2) Any false declaration, false information, or incomplete information on the application form or other application documents including but not limited to omission of information regarding educational background will result in the rejection of my admission or the cancellation of my acceptance into the university. If such a misrepresentation is detected after my enrolment, I will accept any disciplinary actions, such as expulsion from the university or reimbursement of exempted tuition fees, as decided by KUT. Applicant s signature ____________________________________________ Date submitted ____________________ (should be hand-written) 00000000000000000000000000 0 Year / Month / Day Send the completed application form together with other required documents to: International Relations Division Kochi University of Technology Tosayamada, Kami City Kochi 782-8502, JAPAN Tel: +81-887-53-1130 Fax: +81-887-57-2000 E-mail:international@ml.kochi-tech.ac.jp 00000000000000000*Note: do NOT send application documents via e-mail. 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