Form A (1/ 2)
International Environmental Leadership Program (IELP)
Graduate School of Environmental Studies, Tohoku University
APPLICATION FOR ADMISSION
IELP 2016
Please type or neatly print in English. Check the appropriate boxes.
Applicant’s registration number (for office use)
Master’s course
Doctoral course
Photograph
4×3cm
Name
(1.6"×1.2")
in English
In Chinese
Characters
Write your
LAST name
on the back side.
Family name / First name
(if applicable)
Date of
Year
Month
Day
birth
Nationality
Age (as of April 1, 2015)
Gender
Male
Female
Present status
(with name and address of university or employer)
Present mailing
address
Phone number
Fax number
E-mail address
Permanent
address
(if different from above)
Phone number
Fax number
Expected laboratory
Expected Supervisor
Have you ever received the MEXT (Japanese Government) scholarship?
Yes
No
Yes
No
Do you intend to enter IELP even if you are NOT awarded the MEXT scholarship?
Yes
No
Are you applying for, or going to receive, any other scholarships?
Yes
No
Yes
No
If Yes: [Program]
[Host institution]
[Term] From
/
to
/
(yyyy/mm)
For master's course candidate:
Do you intend to continue to study in the doctoral course of the IELP?
If YES, provide some information of the scholarship. (Name, sponsor, duration, etc.)
Are you applying for any other graduate schools?
List institutions, programs, or positions you are currently applying for. (Optional)
Form A (2/ 2)
APPLICATION FOR ADMISSION
IELP 2016
Educational background
Name and address of School
Elementary
Education /
Elementary School
Name
Secondary
Education / Lower
Secondary School
Name
Upper Secondary
School
Name
Higher Education /
Undergraduate
Level
Name
Year, month and date of
entrance and completion
(yyyy / mm / dd)*required
From
To
Location
From
To
Location
From
To
Location
From
To
Location
Name
From
Graduate level
To
Location
Total years of schooling mentioned above
Amount of time spent at
the school attended
years and
months
years and
months
years and
months
years and
months
years and
months
When taking leave
of absence, the
period and reason
years
Research activities record
Name of institution
Position
from (yyyy / mm / dd) to
Number of years
From
To
From
To
From
To
Employment record
Name of office
Position
from (yyyy / mm / dd) to
Number of years
From
To
From
To
From
To
Family name
Name
First name
Middle name
Type or name
Acquired date
Name of institution
Degree
Have you ever visited Japan?
Yes
No
If YES: [Term]
[Purpose of Stay (e.g. Sightseeing, Exchange programs, etc.)]
What is your primary (first) language?
I hereby certify that the information on this application form is true and complete.
I understand that the falsification in any of the information on the form may result in admission denial.
Signature:
安全保障輸出管理
(for office use)
Date(yyyy/mm/dd):
□ 承認済み（承認日：月
□ 手続不要
□ その他
日）
（確認事務担当者氏名：
）