For the KYOTO UNIVERSITY INTERNATIONAL UNDERGRADUATE PROGRAM 2017

Application Form for the KYOTO UNIVERSITY INTERNATIONAL UNDERGRADUATE PROGRAM 2017

Please Note: 1. This form must be completed in English and in block letters. 2. Numbers should be in Arabic numerals (e.g. 0, 1, 2, 3, etc.). 3. Proper nouns should be written in full （no abbreviations）. 4. This form is also available on our website in PDF format. (Family name) 1. Name of applicant (First name) (as in official ID) (Middle name)

2. Choice of faculty □ Faculty of Integrated Human Studies and course (check one only) □ Faculty of Letters □ Faculty of Education □ Faculty of Law □ Faculty of Economics □ Faculty of Science □ Faculty of Engineering (For Engineering, check one course from below) □ Global Engineering □ Architecture □ Engineering Science □ Electrical and Electronic Engineering □ Informatics and Mathematical Science □ Industrial Chemistry □ Faculty of Agriculture (For Agriculture, check one course from below) □ Bioresource Science □ Applied Life Sciences □ Agricultural and Environmental Engineering □ Food and Environmental Economics □ Forest and Biomaterials Science □ Food Science and Biotechnology *If you select the Faculty of Engineering or Faculty of Agriculture, you must also select the course to which you wish to apply. *Please select your first choice only.

3. Gender ☐ Male ☐ Female 4. Marital status ☐ Married ☐ Single 5. Nationality

6. Date of birth (Month) (Date) (Year)

Form A-1

Place of birth

7. Current academic status (name and address of current school, etc.)

8. Current address

(Home) country code + 9. Phone number (Mobile) FAX number E-mail address *An e-mail address is essential for communications relating to the admission process. If the Admissions Office has trouble contacting you, you may be placed at a disadvantage. 10. Educational background (fill in your educational background precisely and in chronological order) From To Type of school Country Name of school (Month) (Year) (Month) (Year)

Total years of primary and secondary education: ( ) years ( ) months Undergraduate Name of university or college From To education (Month) (Year) (Month) (Year) (If applicable)

11. Employment record From To Name of company (and location) (Month) (Year) (Month) (Year)

12. Language background (indicate languages known, and in which language the applicant is most proficient) Language Level of proficiency

13. Person to be notified in the applicant’s home country in case of emergency Name Relationship

Form A-2 Address

(Home) country code + Phone number (Mobile) FAX number E-mail address

14. Family or relatives in japan (if any) Name Relationship

Address

15. Source(s) of funds for payment of tuition and living expenses in Japan (the amounts must be entered).

☐ Amount /per month Scholarship (currency: ) Name of Scholarship Name and address of sponsoring organization

☐ Amount /per month Family support (currency: ) Name Relationship

Address

☐ Amount /per month Other (currency: ) Name Relationship

Address

16. English proficiency test scores (*Must be provided)

☐ TOEFL (☐ iBT / ☐ PBT)

Examination date Score

☐ IELTS (academic module)

Examination Date Score Official score Order date ( )

17. About your Japanese language ability (*Must be completed)

Form A-3 1. Reading □Excellent □Good □Adequate □Poor 2. Writing Please fill in all four □Excellent □Good □Adequate □Poor criteria 3. Speaking □Excellent □Good □Adequate □Poor 4. Listening □Excellent □Good □Adequate □Poor Approximate total number of hours of Japanese study during the past year hours

18. Submission of JLPT Score (*Optional)

☐ JLPT (The Japanese Language Proficiency Test)

Examination date Level

19. Submission of examination score (Examination for Japanese University Admission for International Students [EJU] or national standard test) (*Optional)

☐ EJU (*Be sure to enclose a copy of the examination voucher for the EJU.) Date of Examination site examination Examination language ☐ English ☐ Japanese Examination registration number * * EJU scores Math 2: Physics: Chemistry: Honors scholarship for EJU takers ☐ I have been selected as an awardee by JASSO for 2017 university admission. ☐ National standard test: name of test ( )

Date of examination

Examination Language

☐ Mathematics for science courses ☐ Physics ☐ Chemistry Examination subjects ☐ General science, including physics & chemistry

I certify that all of the information I have provided in this application form and in any accompanying documents is true. Date:

Signature: (*Please sign your name by hand.)

Form A-4