Please Submit the Application Form to Your International Office

Saitama University Summer Program 2017 Application Form I. Personal Information

______/ ______/ ______Name First Middle Family

Date of Birth Year Month Day Gender □ Male □ Female Nationality Native Language

Present Address

Email Phone Number Passport Number Passport Expiration Date / / Visa Assistance Do you need visa assistance to enter Japan? □ YES □ NO II. Current Academic Status Institution/University Degree Course □ Undergraduate □ Master □ Doctor Major Grade □ Freshman □ Sophomore □ Junior □ Senior Language of Study III. Others

English Level □Native □Non-native

□TOEFL/PBT ( ) □TOEFL/iBT ( ) □IELTS ( ) English Score □Other ( ) Please answer either score if you are Non-native.

Please submit the Application Form to your International Office. Handwriting is not acceptable.

I hereby certify that the above information is complete and accurate. And when accepted by Summer Program 2017 I shall abide by the regulations of Saitama University and laws of Japan.

Signature

Date *Please read the next page carefully before you apply.

NOTICE 1. Participants in the program are required to purchase travel insurance at their own expense to cover the period of their stay in Japan. 2. Saitama University will only provide assistance in obtaining a visa to students from our partner institutions. 3. We reserve the right to make use of any personal information provided on the application form in order to implement and manage the program. 4. Please prepare your own full coverage of Study Abroad Insurance before you leave for Japan.

※Please submit the following documents to your International Office. 1. Application Form with one photo (4 x 3 cm, color): It should be an official photo such as for a passport or driver’s license. 2. An official transcript from the applicant's home institution 3. An official English test score (Non-native speakers of English only) 4. Your passport copy 5. ID Photo file (we will use for student ID card)