TOMODACHI Aflac Program
- Scholarship for pediatric cancer-specialized doctors to study abroad -
Application Form
DOB
Kana
Signature
Name
MM/DD, YY
Age
Male/female
Sex
Photo
3.5 cm × 4.5cm
Address
（
Phone:
）
Professional affiliation
Name
Office/
Title
department
Phone:
(
)
Fax:
(
)
Location
Profile
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
Year
Month
(Name of university)
1/5
(Year of graduation)
TOMODACHI Aflac Program
- Scholarship for pediatric cancer-specialized doctors to study abroad -
Recommendation Letter
Name of the applicant
Recommendation letter (by the person responsible for the office/department)
MM/DD, YY
Name of office/dept.
Title:
Name:
Signature
Written permission for the applicant to study abroad (by the person with responsibility)
I permit the above named to study abroad under the conditions below.
Where the applicant is to study abroad:
From:
MM/YY
To:
MM/YY
MM/DD, YY
Name of the office/department:
Title:
Name:
2/5
Signature
TOMODACHI Aflac Program
- Scholarship for pediatric cancer-specialized doctors to study abroad Name of the applicant
Any applications filed for other scholarship programs
1.No
2. Yes
If you choose “2. Yes” above
A．Already applied B. Plan to apply
Name of the sponsor:
Amount of the scholarship:
Language proficiency
TOEIC:
TOEFL:
Eiken (to test
Experience studying
practical English
Level:
abroad:
proficiency):
3/5
TOMODACHI Aflac Program
- Scholarship for pediatric cancer-specialized doctors to study abroad -
List of Achievements
Name of the applicant
List of achievements in the recent 5 years
[Original papers, reports and articles]
[Presentations at academic meetings]
[Reviews, school textbooks]
4/4
TOMODACHI Aflac Program
- Scholarship for pediatric cancer-specialized doctors to study abroad -
Outlined Theme of the Study at the Aflac Cancer Center
Name of the applicant:
aaa
The reason you seek to study abroad
Theme of the study at the Center
Summary of the study (up to 1,000 words)
5/5