<Office Use Only>
Application Form
School of International Liberal Studies,
Waseda University
2012 AO April Entry (Overseas)
How to Complete This Form
* Type or Write in English in a black ink. * A non-refundable application fee must accompany this application. See section 11. * Ensure that you complete the checklist and sign the declaration. See sections 9 and 13.
Section 1
Personal Details
* Type or Write in a black ink using BLOCK LETTERS (as written in your passport).
FAMILY NAME:
* full legal name
GIVEN NAME:
* full legal name
MIDDLE NAME:
* full legal name
NAME in Chinese
characters: * If any
NAME in KATAKANA:
* If any
Date of Birth:
Year:
Y
Y
Y
Y
Month:
M
M
D
Date:
Gender:
D
M
Male:
* Check □✔ one.
F
Female:
CURRENT ADDRESS * In English
Country/ Region of
Citizenship:
Do you have a Japanese visa?
No
Yes
If "Yes", please specify:
* If available, write it in Chinese characters
Y
Date of expiry:
Y
Y
Y
M
M
D
D
What is your first language? * Check □✔ one.
English
Postcode/
Zip:
Telephone:
Japanese
years
Study Plan 1
< Study Plan > Check □✔ one.
*Refer to Admission Guide, Step 1-9 Study Plan. Then, be sure
to choose one.
Study Plan 2
CURRENT ADDRESS:
< Mailing Address > Check □✔ one.
* Specify the mailing address at which you
E-mail:
*mandatory
PERMANENT HOME ADDRESS:
would like to receive the result.
OTHER ADDRESS:
PERMANENT HOME ADDRESS * If same as Current Address, write "As above"
OTHER ADDRESS
Postcode/
Zip:
Postcode/ Zip:
Country/
Region:
Telephone:
Mobile:
Other(specify)
*(Country Code, Area Code, Local Code)
Mobile:
FAX:
J
*(Country Code, Area Code, Local Code)
*(Country Code, Area Code, Local Code)
FAX:
E
* If English is not your first language, indicate the
number of years of English instruction you have
received:
Country/
Region:
*(Country Code, Area Code, Local Code)
Telephone:
*(Country Code, Area Code, Local Code)
FAX:
*(Country Code, Area Code, Local Code)
* In English
*If any
Country/
Region:
*(Country Code, Area Code, Local Code)
*(Country Code, Area Code, Local Code)
*(Country Code, Area Code, Local Code)
Mobile:
Section 2
Photograph
Photo CARD
Attach Your
Color Photograph
(4cm×3cm)
Application for
2012 AO April Entry (Overseas)
* Taken on or after July 1st, 2011.
* Print your name on the back of
the photograph.
* 4cm long and 3cm wide.
* Borderless and taken against a
plain background.
* Look straight ahead with your
head uncovered.
FAMILY NAME:
School of International Liberal Studies
Waseda University
<Office Use Only>
GIVEN NAME:
MIDDLE NAME:
Page - 1 -
<Office Use Only>
Section 3
Educational Background
* List in English, in chronological order, all schools attended starting from primary school
Location of School
Name of School
Period of Attendance
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
City:
Country / Region:
Year:
Month:
Date of High School Graduation:
Year
Y
Y
Y
Y
Month
M
M
Date:
D
D
Date of High School Equivalency
Examination
Year
Y
Y
Y
Y
Month
M
M
Date:
D
D
Graduated or Expected:
～
～
～
～
～
～
～
～
～
～
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Year:
Month:
Graduated:
Check □✔ one.
Total Period of Education:
Expected:
Years
Months
* e.g.) GED(USA), Certificate for Students Achieving the Proficiency Level of Upper Secondary School Graduates(Japan), etc.
Section 4
Test Information
* Please write your results in the following tests and enclose the original score card with this application form.
English Proficiency
Date Taken (Year / Month):
Score:
Score Report to Be Directly Sent
from Institution:
* Check □✔, in case.
Date Taken (Year / Month):
Score:
TOEFL (iBT)
Year
Y
Y
Y
Y
Month
M
M
TOEIC:
Year
Y
Y
Y
Y
Month
M
M
TOEFL (CBT)
Year
Y
Y
Y
Y
Month
M
M
GEPT:
Year
Y
Y
Y
Y
Month
M
M
TOEFL (PBT)
Year
Y
Y
Y
Y
Month
M
M
EIKEN:
Year
Y
Y
Y
Y
Month
M
M
IELTS:
Year
Y
Y
Y
Y
Month
M
M
University Entrance Qualification Examination
Date Taken:
Year:
Y
Y
Y
Y
Month:
M
Directly Sent From Institution:
* Check □✔, in case.
M
SAT Reasoning
Test
Critical Reading:
ACT
Date Taken:
Year:
Y
Y
Y
Y
Month:
M
M
Score (Composite)
Directly Sent From Institution:
* Check □✔, in case.
International
Baccalaureate
Date Taken:
Year:
Y
Y
Y
Y
Month:
M
M
Score (Total)
Directly Sent From Institution:
* Check □✔, in case.
Math:
Writing:
Total:
* If you have taken other test: ex) GCE-A level, GAO-KAO, Korean CSAT, Ontario/BC Provincial etc, write your results below.
Test Name
Country / Region
Date Taken (Year / Month):
Score
Year:
Y
Y
Y
Y
Month:
M
M
Year:
Y
Y
Y
Y
Month:
M
M
Other Tests
◆(1) For those who are scheduled to take the national standardized test (Korean CSAT, Thai O-Net, Australian standardized test or New Zealand's NCEA Level 3) etc, and to graduate from your school, check□✔ and write the following
information.
I cannot submit the national standardized test result in time since it comes out after my application.
Test Name
Country / Region
Date to Be Taken (Year / Month):
Year:
Y
Y
Y
Y
Month:
M
M
◆(2) If the country or region where you are receiving or have received your education has no national standardized test for assessing your qualification to enter university, check □✔ and write the following information.
I cannot submit the national standardized test result
Country / Region
Page - 2 -
<Office Use Only>
Section 5 Plans
* Please write about BOTH topics.
TOPIC No. 1
Describe what you plan to study for 4 years at SILS, explaining the areas of study you intend
to focus on and giving specific reasons. (within 200 words)
Description
TOPIC No. 2
Describe how you see your future path after graduation from SILS. (within 200 words)
Description
Page - 3 -
<Office Use Only>
Section 6
Academic Honors and Personal Activities
* If you would like to tell us your academic honors or personal activities after graduating from junior high school, choose up to three honors/activities as you think best in order. Describe them in the following given spaces and enclose a
photocopy of any proof documents. Indicate the reference No. on each document to certify. (within 150 words each)
Ref. No.
Name of Honor / Activity
Date Taken
(Year/ Month)
1.
Description
Ref. No.
Name of Honor / Activity
Date Taken
(Year/ Month)
2.
Description
Ref. No.
Name of Honor / Activity
Date Taken
(Year/ Month)
3.
Description
Section 7
Experience of Studying Abroad
* If you have some experience of studying abroad after graduating from junior high school, describe it and enclose a photocopy of your certificate of school and transcript. Indicate the reference No. on each document to certify.
Location of School
Ref. No.
Name of School
Period of Attendance
1.
City
Country / Region
Year:
Month:
～
Year:
Month:
2.
City
Country / Region
Year:
Month:
～
Year:
Month:
3.
City
Country / Region
Year:
Month:
～
Year:
Month:
4.
City
Country / Region
Year:
Month:
～
Year:
Month:
Page - 4 -
<Office Use Only>
Section 8
Section 11
Interview Questionnaire
Place
1st Batch
☑
2nd Batch
☑
October 22 (SAT), 2011
I paid from outside Japan. I attach a copy of my remittance form to the Application Form and
enclose it with other materials.
November 26 (SAT), 2011
Tokyo
(Waseda University)
Bangkok
(Thailand)
Beijing
(China)
Bonn
(Germany)
Portland, OR
(USA)
Seoul
(Korea)
Shanghai
(China)
December 3 (SAT), 2011
October 29 (SAT), 2011
December 3 (SAT), 2011
October 22 (SAT), 2011
December 3 (SAT), 2011
October 29 (SAT), 2011
November 26 (SAT), 2011
October 21 (FRI), 2011
December 2 (FRI), 2011
October 22 (SAT), 2011
November 26 (SAT), 2011
October 29 (SAT), 2011
November 26 (SAT), 2011
Section 12
* To be completed by all applicants. We would be grateful if you let us know the following questions.
1) How did you find out about the SILS? Please check □✔ one box only.
October 22 (SAT), 2011
November 26 (SAT), 2011
Taipei
October 29 (SAT), 2011
November 26 (SAT), 2011
Date:
Place:
Others
*specify
Section 9
I paid from within Japan at a convenience store. I paste the "Certificate of Payment of the
Screening Fee" on the following space.
October 29 (SAT), 2011
Singapore
(Taiwan)
Screening Fee
* A non-refundable Screening Fee must be paid with each application form submitted. Applicants will not be processed
unless accompanied by the Screening Fee. Complete this section and check □✔ one carefully. For more details refer
to the admission guide, [Step 2-2: how to pay for Screening Fee]
* Be sure to choose one or two among the following scheduled interviews, and check □✔.
<Only Those who Make Payment in Japan>
Attach your "Certificate of Payment of the Screening Fee"
I am non-Japanese and reside outside Japan. Acquaintances in Japan have paid the fee by
the money transfer form designated by the School. I attach the "Certificate of Payment of the
Screening Fee" and enclose it with other materials.
I have attached and submitted together with my application form the "Application Form for a
Screening Fee Waiver 2012 WASEDA University" and thus request to be exempted from the
screening fee under the system that exempts applicants from designated countries.
Visiting WASEDA University Staff
Member
Graduate/s of WASEDA University
Check List (Application Documents)
①: Application Form
Yes
No
②: English Essay
* specify (
Advertisement in Newspaper
/ Magazine
* Complete the following checklist before submitting and include original or certified copies of the following
documents with your application.
No
WASEDA University/SILS Website
Other Website
Date:
Place:
Yes
Questionnaire (For statistical purpose only)
)
WASEDA University Information Session
* specify place (
)
WASEDA University Representative
Open Campus at WASEDA
Family / Friends
Education Fair
Your High School
Other * specify (
)
2) Please list any other schools of Waseda or universities you are applying for, or intend to apply for, if any.
Yes
No
③: Document to Prove Your Applicant Qualification
Yes
No
④: Academic Transcript
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(
)
Section 13
Declaration and Signature
⑤: Certificate of Results of University Entrance
* Once you have completed all previous sections, read this section (Declaration and Signature) below and sign to indicate
Qualification Examination(s) and Other Standardized
you agree with its terms;
Tests
⑥: English / Japanese Translation of ③・④・⑤ above
1. I declare that the information provided by me is true and complete in every particular.
Notarized by an Embassy or Another Appropriate Office
2. I acknowledge that all documents submitted become the property of WASEDA University and will not
⑦: English Proficiency Test Score
be returned.
3. I acknowledge that the provision of incorrect information or the withholding of relevant information
⑧: Letter to Explain in English the Reason Why You Are
relating to my application, including academic transcripts, might invalidate my application and that
Unable to Submit of ④・⑤・⑦ above.
WASEDA University may withdraw an offer of a place or cancel my enrollment in consequence.
⑯: Certificate of Items Stated in the Alien Register or
4. I understand that WASEDA University reserves the right to inform other tertiary institutions if any of the
Copies of Both Side of the Alien Registration Card
material presented to support my application is found to be false.
* if you are non-Japanese and reside in Japan.
Section 10
5. I consent to any educational institution at which I have previously been a student and/or my current or
any past employer, providing WASEDA University with information which that institution holds about
me for the purpose of WASEDA University verifying my grades and/or qualifications or experience.
Check List (COE Documents)
* Check □✔ one.
I desire to have SILS as my proxy to obtain the "Certificate of
Eligibility (COE)" from the Tokyo Immigration Bureau of the
Ministry of Justice.
Yes
No
* If "Yes", complete the following checklist before submitting and include the following documents with your
application.
6. (In the case that the applicant asks Waseda University to submit an application for a Certificate of
Eligibility on the applicant's behalf) I acknowledge that WASEDA University will not be held
responsible for any disadvantages incurred should the Ambassador/Consul of Japan decides to delay
or deny my request for a student visa due to a problem with the documents I submitted.
7. (In the case that the applicant does not ask WASEDA University to submit an application for a
Certificate of Eligibility on the applicant's behalf) I acknowledge that WASEDA University will not be
held responsible for any disadvantages incurred should the Ambassador/Consul of Japan decides to
delay or deny my request for a student visa.
Yes
No
⑨: Statement of Financial Resources
Yes
No
⑩: Certificate of the Deposit Balance of a Bank Account
Yes
No
⑪: Agreement for Defraying Expenses
8. I declare that I will be able to abide by the statutes, regulations and policies on admission, fees
payments and fee refunds of WASEDA University.
Yes
No
⑫: Application for a Certificate of Eligibility (COE)
9. I have read and understood the above conditions and accept them in full.
Yes
No
⑬: Personal History
Yes
No
Yes
No
Student Signature :
⑭: Copy of Your Passport
FULL NAME :
* if you have one
* PRINT as written in your passport
⑮: Copy of Your Resident Card
* if you are Korean
Date:
Year
Y
Y
Y
Y
Month
M
M
Date
D
D
* Do NOT change the format so that the Application Form fits in the given 5 pages.
Page - 5 -