Application Form 2016
Advanced Graduate Program in Global Strategy
for Green Asia (Green Asia Program)
Kyushu University
For office use only
Examinee number
This is the application form for enrolment into the Advanced Graduate Program in Global Strategy for Green Asia (Green
Asia Program), Kyushu University from October 2016.
All fields must be completed, and failure to complete some fields may delay the processing of the application.
There is no payment required with the submission of this form.
Please read the Guidelines for Application Submission very carefully.
If completing by hand, please write in BLOCK LETTERS using black ink only, however electronic format is preferable.
Section A: Applicant’s Personal Details
Please enter your full legal name exactly as it appears on your passport (See Note 1).
Title:（Mr,Ms,
Mrs, Miss,Dr)
Family Name:
Please paste the portrait
photo here.
First Name:
Gender
□
□
Male
Female
Middle Name(s):
Date of birth
day ____ month _____ year _________
Section B: Contact Information
(See Note 2)
Home address:
Correspondence address (if different):
City:
City:
Postal code:
Postal code:
State or Province:
State or Province:
Country:
Country:
Telephone (home):
Telephone (mobile):
Country
Code:
Country
Code:
Area
Code:
Area
Code:
Number:
Number:
E-mail address:
Skype ID (if available):
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Section C: Nationality and Citizenship
Country of Birth:
Please include all countries in which you hold or have held citizenship. If you have renounced your citizenship to a
particular country, please specify the date of renouncement. Please do not specify an end date unless you are no longer a
citizen of that country. If you hold multiple nationalities, please indicate the passport that will be used in order to enter Japan
with an asterisk (*) and by writing it first in the list. Please give the passport number, nationality and expiry date.
From
To
Passport Number and Expiry Date
Nationality
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
COUNTRY OF RESIDENCE.
Please give details for the past 3 years. This should be the country in which you are normally resident but not a country in
which you are temporarily studying. Please do not give an end date unless you no longer reside in that country.
Country
From (dd/mm/yyyy)
To (dd/mm/yyyy)
Section D: Guarantor
(See Note 3)
Relationship to
Applicant:
Name:
Contact
Address:
Tel:
E-mail
Address:
(if available)
Section E: English Language Ability
If you are a citizen of one or more of the following countries where English is an official language, you are exempt from the
language requirements of this application. Tick the box if applicable.
 I am from a country listed below.
 Go to Section F
Antigua and Barbuda, Australia, The Bahamas, Barbados, Belize, Canada, Dominica, Grenada, Guyana, Republic of
Ireland, Jamaica, New Zealand, St Kitts and Nevis, St Lucia, St Vincent and the Grenadines, Trinidad and Tobago,
United Kingdom, United States of America.

Select the appropriate English language
 TOEIC®
 TOEFL® iBT
 IELTS™
qualification.
Please submit with this form a score sheet as
evidence of proficiency in English.
 Other (please specify):
(See Note 4).
Overall Score:
Date of Test:
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Section F: Details of Current and Previous Education
Please include all schools, colleges and universities from your primary level education (See Note 5).
School or Institution
Attended
Total number of years
in full time education
Enrollment Date
Graduation Date
(Month / Year)
(Month / Year)
Remarks
Years:
Section G: Work Experience
Please give details of your past employment history (if any).
Name of Organization
Period of Work (mm/yyyy)
From
To
From
To
From
To
3
Position
Office use only
Responsibilities
Section H: Details of Home Institution
If you are currently enrolled in, or have recently graduated from an institution outside Japan, please provide the details of
the home institution below.
Home Institution Name:
Address:
City or Town:
Zip Code and Country:
Name of Department or Faculty:
Name:
Academic Advisor or Supervisor
Title:
Position:
E-mail address:
Section I: Details of Referees
Please nominate TWO Referees and attach their corresponding reports to this application form.
Title:
Name:
Name of Institution, Faculty and
Department:
Referee 1
Telephone:
Contact
Address
E-mail Address:
Postal Address:
Title:
Name:
Name of Institution, Faculty and
Department
Referee 2
Telephone:
Contact
Address
E-mail address:
Postal Address:
Section J: Preferred Supervisor
If you do NOT have an invitation letter from a professor of the Green Asia Program, please select up to three preferred
professors and laboratories from the list provided in Note 6.
Number
Laboratory / Professor
st
1 preference
2nd preference
3rd preference
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Section K: Personal Statement
Please provide a personal statement of between 200–300 words, which informs us of your desire to join the Green Asia
Program. You should give details of your academic interests, future plans and how the qualification will enhance your
career. Also briefly summarize your academic career to date and the various skills and knowledge that you will bring to the
program.
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Section L: Check List
Please check carefully you have fulfilled the following requirements before submitting this application form.
 Completion of the application form 
 A copy of the academic transcript(s)
 A copy of the English proficiency certificate 

 Report by Referee 1
Check the above box only if the report has been sent to the Green Asia Education Center Office via email directly
from the referee, or an envelope sealed with the report has been posted to the office by registered mail and a delivery
confirmation was received from the office.

 Report by Referee 2 
Check the above box only if the report has been sent to the Green Asia Education Center Office via email directly
from the referee, or an envelope sealed with the report has been posted to the office by registered mail and a delivery
confirmation was received from the office. 

 A copy of your passport (photograph and information page)
 An invitation letter from a professor of the Green Asia Program (optional)
Name of the professor:
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