UC Berkeley/Davis Programs (Administered by the Division of International Affairs, The University of Tokyo)
(AY2015-16)
Internal Application Form
YYYY / MM / DD
1. Name
*In Japanese and English
as shown on passport
Example）スミス ジョン
SMITH John (FAMILY→Given)
3. Basic Information
Age:
(As of April 1, 2015)
Date of Birth:
(YYYY/MM/DD)
Gender:
Nationality:
(Non-Japanese nationals) Do you have permanent residence in japan? □Yes □No
(Non-Japanese nationals) Awarded Japanese Government Scholarships?
□Yes □No
4. Contact
5. Emergency Contact
6. Academic Affiliation and
Year at the time of Study
Abroad
2. Student ID
No.
Cell-phone No.:
E-mail (PC):
Address: 〒
Name:
Address :
Relationship to you:
Graduate School/
Faculty/Department
(Entrance Year/Month)
Phone No. :
(YYYY / MM)
Year of Study
Supervisor Name
Extension No.
(insert details if you have a supervisor)
7. Estimated date of
Expected to graduate: (YYYY / MM)
graduation if you go abroad
*Please give the expected date of graduation having participated in this program
to study
8. Status while abroad
□ “Study Abroad” (Ryu-gaku「留学」)
□ “Leave of Absence” (Kyu-gaku「休学」)
UC Berkeley American and International Study Program (AISP)
（ ）Fall Semester only：August 2015 – December 2015
（ ）Spring Semester only：January 2016 – May 2016
（ ）Fall & Spring Semester：August 2015 – May 2016
9. Period you wish to be （ ）UC Davis Global Study Program
Period of choice：＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿ (Select from below)
abroad
・Fall Quarter only：September 2015 – December 2015
(Please indicate your
・Winter Quarter only：January 2016 – March 2016
order of preference)
・Spring Quarter only：March 2016 – June 2016
・Fall & Winter Quarters：September 2015 – March 2016
・Winter & Spring Quarters：January 2016 – June 2016
・Fall, Winter & Spring Quarters：September 2015 –June 2016
10. Grading Coefficient
All semesters:
Last academic year (AY 2014):
* Insert Coefficient from the Grading Coefficient Calculation Table
(
11. English Proficiency
) TOEFL iBT
Total Score:
(
(
) IELTS
Date Taken: (YYYY/MM)
Reading(
), Listening(
Speaking(
), Writing(
)
)
) Other Explanation:
12. Application to Other
Programs &
Special Notes
- If also applying (or planning on) to programs other than UC Berkeley/Davis Programs, please list those
programs’ name and universities.
- If you are currently studying abroad, please note the host country/institution/name of the program/duration
of study abroad
- If there are other considerations you would like to note, use this space.
13. Confirmation of
Personal Information
①If you pass the internal screening, would you like us to share your contact information (name and email)
with other UTokyo students participating in the same program to exchange information? ( )Yes ( )No
②After participation, if there is a prospective student who wish to hear past-participant’s experience, can
we share your information (name and email) to him/her? ( )Yes ( )No
14.【Required】As an academic supervisor, I understand that the student is applying to the courses/programs listed above.
(Please sign or affix your seal in Japanese or English) *In cases where you do not have an academic supervisor, write “not
applicable”
Supervisor
Department／Position／Name
15.【Required】As the designated coordinator for the department/faculty, I have explained the necessary information and
points of notice to this student applying to the program. (Please sign or affix your seal in Japanese or English)
Designated Coordinator of the applicant’s affiliation at the time of going abroad
Department／Position／Name
16.【Required】I have read the application guideline carefully and confirmed everything stated. I have had the necessary
information and points of notice explained by the faculty/graduate school with which I will be affiliated during the summer
program, and fully understood them on applying for the program. (Please sign or affix your seal in Japanese or English)
Student
Department／Position／Name
17. Profile, Personality, Skills etc. (in Japanese or English) *Make sure to write within this space
【Content to be included】
・Academic and professional background
・Any points you would like to highlight, such as an extracurricular activity, volunteering, personality,
skills etc.
(Delete this textbox for submission)
18. Statement of Purpose (in Japanese or English) *Make sure to write within this space
【Content to be included】
・If you have experience living abroad, list the country, duration and the purpose
・Motivation for applying to the program
・Objectives and aim for joining the program (including your future plans and goals)
・If you wish to apply for both locations, please give statements for both.
(Delete this textbox for submission)
19. Study plan while at UC Berkeley/Davis (in Japanese or English) *Make sure to write within this space
【Content to be included】
・State and give details of the subject you wish to primarily take lectures in
after checking their websites and considering your aim of studying abroad.
・Also write down any other plans you have such as improving your language
proficiency or understanding of their culture.
・If you wish to apply for both locations, please give statements for both.
(Delete this textbox for submission)