受講申込書 - 関西大学

様式 Form ①−1
関西大学 Kansai University
日本語・日本文化教育プログラム語学留学コース
受講申込書
Application Form for Japanese Language and Culture Course（ JLC ）
Attach photo here
（ 4cm × 3cm ）
※日本語または英語で、楷書体にて記入すること。
※ Please fill in either in Japanese or English clearly with block letters.
1 氏 名（ Name ）
漢字またはカタカナ（ Full name in katakana or kanji ）
氏（ Family name ） 名（ Given name ）
アルファベット（ Full name in alphabet ）
（ First ） （ Middle or Other ） （ Last ）
2 国 籍（ Nationality ）
3 性 別（ Sex ） □ 男（ Male ） □ 女（ Female ）
4 生年月日（ Date of birth ）
年（ Year ） 月（ Month ） 日（ Day ）
5 旅券番号（ Passport number ）
有効期限（ Date of expiration ） 年（ Year ） 月（ Month ） 日（ Day ）
6 電話番号（ Telephone ） （ Fax ）
7 住 所（ Mailing address ）
（ E-mail ）
8 在籍大学（ Name of home university ）
9 在籍区分（ Registered program ） □大学（ Undergraduate ） □修士（ Master s course ） □博士（ Doctoral course ）
10 学 部（ Faculty／Course ）
11 年 次（ Current year of study ） □ 1 年次（ 1st year ） □ 2 年次（ 2nd year ） □ 3 年次（ 3rd year ）
□ 4 年次（ 4th year ） □ 5 年次（ 5th year ） □卒業（ Graduated ）
□その他（ Other
）
12 留学開始予定時期（ Intended start of study ） □ 4 月開始（ from April ） □ 9 月開始（ from September ）
13 留学期間（ Terms of enrollment ）
□ 1 学期、6 か月（ 1 semester, 6 months ） □ 2 学期、1 年（ 2 semesters, 1 year ）
様式 Form ①−2
14 大学寮（ University Dormitory ）
□はい、大学寮を希望します。
（ Yes, please arrange my room in the dormitory. ）
□私は大学寮以外の住居を自分で探します。
（ I will find off-campus accommodation myself. ）
学 歴（ Summary of Educational Experience ）
学校名
School Name（ s ）
所在地
City and Country
年 齢
Your ages while attending
入学・卒業年
Calendar years attended
年（ year ）月（ month ）
∼
∼ 年 月
年 月
∼
∼ 年 月
年 月
∼
∼ 年 月
日 本 語 能 力（ Japanese Language Proficiency ）
あなたは、日本語を勉強したことがありますか？（ Have you studied Japanese before? ） □はい（ Yes ） □いいえ（ No ）
何年間くらい勉強しましたか？（ If yes, how long have you studied Japanese? ）
約（ about ） 年（ Years ） 月間（ Months ）
日本留学試験（日本語）（記述を除く点数の合計）
点 □未受験
Examination for Japanese University Admission for International
（ except writing ）
Students（ Japanese as a foreign language ）
points Never taken
級合格
日本語能力試験
点 □未受験
Japanese Language Proficiency Test
level passed
実用日本語検定（ J. Test ）
級合格
Test of Practical Japanese（ J. Test ）
points Never taken
点 □未受験
level passed
points Never taken
英語能力（ English Language Proficiency ）
母語（ Native language ）
□ English
□ Others（
TOEFL
PBT □
CBT □
）
iBT □
IELTS
点
points
その他の資格（ Others ）
点
points
留学の目的（ Statement of purpose for your study abroad ）
※可能な限り日本語で記入のこと。
（ If you have learned Japanese, try to write in Japanese. ）
様式 Form ①−3
申込者誓約事項（ Applicant s Declaration ）
1 本申請書に虚偽事項のないことを誓います。
I declare that all my statements in this application are true.
2 語学留学コース受講案内を熟読し、理解しました。
I have read and understood the Admission Guide for JLC.
3 滞在中については、日本の国民健康保険に加入することに同意します。
I agree to join Japanese National Health Insurance during my stay.
4 関西大学での留学に際しては、大学のすべての規則を遵守します。
I will conform to all University regulations while studying at Kansai University.
署名
Signature
日付
Date
年
year
月
month
日
day
保証人（経費支弁者）（ Guarantor/Sponsor ）
※保証人が記入してください。Must be filled by the guarantor/sponsor.
関西大学 学長 殿
私は、申込者
が関西大学語学留学コースを受講する間、
経費支弁を含む申込者本人に関する一切の事項について保証します。
To: The President of Kansai University
I will bear full responsibility including financial matter for the applicant,
,
for the duration of his/her studies in JLC at Kansai University.
保証人名
Name of Guarantor/Sponsor
出願者との関係
Relationship to the applicant
電話
Tel.
E メール
E-mail
住所
Address
勤務先名
Name of employer
職業
Occupation
勤務先住所
Office Address
署名
Signature
年収
Annual income
日付
Date
年
year
月
month
日
day
様式 Form ②
関西大学 健康診断証明書
Kansai University Certificate of Health
医師により日本語または英語で記載してください。
To be completed in Japanese or English by the examining physician.
氏 名 Name ， □男 Male □女 Female
Family First Middle
生年月日 Date of Birth（ yyyy/mm/dd ） ／ ／ 年齢 Age 身体測定 Physical Examinations
身 長 Height cm 体重 Weight Kg
血 液 型 Blood Type A B O A B Rh ／ ＋ ―
聴 力 Hearing □正常 Normal □所見あり Impaired
視 力 Eyesight （ R ） （ L ） （ R ） （ L ） 裸眼 without glasses 矯正 with glasses or contact lenses
エックス線検査 （ 6 ヶ月以内のものに限る）
X-ray Examination（ Must have been taken within 6 months. ）
肺 lung □正常 normal □所見あり impaired
心拡大 cardiomegaly □正常 normal □所見あり impaired
（心拡大がある場合のみ）心電図 □正常 normal □所見あり impaired
（ in case of cardiomegaly ）Electrocardiogram
← Describe the condition of applicant s lungs.
Date ／ ／ 既往歴 Past history : Please indicate with ＋ or − and fill in the date of recovery.
結核 Tuberculosis □（ ／ ／ ）
マラリア Malaria □（ ／ ／ ）
その他、伝染病 Other communicable disease □（ ／ ／ ）
てんかん Epilepsy □（ ／ ／ ）
腎疾患 Kidney Disease □（ ／ ／ ）
心疾患 Heart Disease □（ ／ ／ ）
糖尿病 Diabetes □（ ／ ／ ）
薬物アレルギー Drug Allergy □（ ／ ）
心理的障害 Psychological disorder □（ ／ ／ ）
身体機能障害 Functional Disorder in extremities □（ ／ ／ ）
現在治療中の病気 □ Yes（ Disease：
）
Disease treated at present □ No
「はい」と答えた場合、薬品の服用や治療を日本での滞在中も続ける必要がありますか？
□ Yes □ No
If yes, does he/she need to continue taking medication or treatment during his/her stay in Japan?
「はい」と答えた場合、現在服用中の薬品や受けている治療について詳細を教えてください。
If yes, please provide detailed information regarding the medication or treatment he/she has been taking:
薬品・治療の種類 Type of medication/treatment:
（
）
頻度 Frequency （ ）times（ per week・per day ）
診察医の印象を述べてください。Please describe your impression.
本人の診断・検査の結果や既往症から判断して、現在の健康の状況は日本への留学に十分耐えうるものと思われますか？
In view of his/her medical history and above findings, is it your observation his/her health status is adequate to pursue studies in Japan?
□ Yes □ No
日 付 Date ／ ／ 署 名 Signature 医 師 氏 名 Physician s name in print
検査施設名 Office/Institution
所 在 地 Address
ูグ➨භྕ䛾୕ᵝᘧ䠄➨භ᮲䛾஧㛵ಀ䠅
⏦ㄳே➼సᡂ⏝㻌䠍
᪥ᮏᅜᨻᗓἲົ┬
Ministry of Justice, Government of Japan
For applicant, part 1
ᅾ䚷␃䚷㈨䚷᱁䚷ㄆ䚷ᐃ䚷ド䚷᫂䚷᭩䚷஺䚷௜䚷⏦䚷ㄳ䚷᭩
APPLICATION FOR CERTIFICATE OF ELIGIBILITY
ධᅜ⟶⌮ᒁ㛗䚷䚷Ẋ
኱㜰
To the Director General of
෗ ┿
Regional Immigration Bureau
䚷ฟධᅜ⟶⌮ཬ䜃㞴Ẹㄆᐃἲ➨䠓᮲䛾䠎䛾つᐃ䛻ᇶ䛵䛝䠈ḟ䛾䛸䛚䜚ྠἲ➨䠓᮲➨䠍㡯➨䠎ྕ䛻
ᥖ䛢䜛᮲௳䛻㐺ྜ䛧䛶䛔䜛᪨䛾ド᫂᭩䛾஺௜䜢⏦ㄳ䛧䜎䛩䚹
㻼㼔㼛㼠㼛
Pursuant to the provisions of Article 7-2 of the Immigration Control and Refugee Recognition Act, I hereby apply for
the certificate showing eligibility for the conditions provided for in 7, Paragraph 1, Item 2 of the said Act.
㻌
㻌
㻠㻜㼙㼙㽢㻟㻜㼙㼙
䚷
㻝䚷ᅜ䚷⡠䞉ᆅ䚷ᇦ
㻞䚷⏕ᖺ᭶᪥
ᖺ
᭶
᪥
Nationality/Region
Date of birth
Year
Month
Day
Family name
Given name
㻟䚷Ặ䚷ྡ
Name
㻠䚷ᛶ䚷ู
⏨
䞉
Sex
Male
/ Female
ዪ
㻡䚷ฟ⏕ᆅ
㻢䚷㓄അ⪅䛾᭷↓
Place of birth
㻣䚷⫋䚷ᴗ
᭷
↓
䞉
Married /
Marital status
Single
㻤䚷ᮏᅜ䛻䛚䛡䜛ᒃఫᆅ
Occupation
Home town/city
㻥䚷᪥ᮏ䛻䛚䛡䜛㐃⤡ඛ 㛵す኱Ꮫᅜ㝿ᩍ⫱䝉䞁䝍䞊䠄᪥ᮏㄒ䞉᪥ᮏᩥ໬ᩍ⫱䝥䝻䜾䝷䝮ㄒᏛ␃Ꮫ䝁䞊䝇䠅
Address in Japan
኱㜰ᗓ྿⏣ᕷᒣᡭ⏫㻟୎┠㻟␒㻟㻡ྕ
㟁ヰ␒ྕ
㻝㻜䚷᪑ๆ
ᦠᖏ㟁ヰ␒ྕ
㻜㻢㻙㻢㻟㻢㻤䠉㻝㻝㻣㻠
Telephone No.
Cellular phone No.
㻔㻝㻕␒䚷ྕ
Passport
ᖺ
᭶
᪥
Year
Month
Day
㻔㻞㻕᭷ຠᮇ㝈
Number
Date of expiration
Purpose of entry: check one of the followings
㻝㻝䚷ධᅜ┠ⓗ㻌䠄ḟ䛾䛔䛪䜜䛛ヱᙜ䛩䜛䜒䛾䜢㑅䜣䛷䛟䛰䛥䛔䚹䠅
䕕 㻌䠥㻌䛂ᩍᤵ䛃
䕕 㻌䠥㻌䛂ᩍ⫱䛃
䕕 㻌䠦㻌䛂ⱁ⾡䛃
䕕 䠦䛂ᩥ໬άື䛃
䕕 䠧㻌䛂᐀ᩍ䛃
"Professor"
"Instructor"
"Artist"
䕕 㻌䠨㻌䛂௻ᴗෆ㌿໅䛃
"Cultural Activities"
䕕 㻌㻹㻌䛂⤒Ⴀ䞉⟶⌮䛃
"Intra-company Transferee"
䕕 㻌䠪㻌䛂◊✲䛃
"Business Manager”
"Researcher (Transferee)"
䕕 䠪㻌䛂ᢏ⬟䛃
"Engineer / Specialist in Humanities / International Services"
䕕㻌䠪䛂≉ᐃάື䠄◊✲άື➼䠅䛃
䕕 㻌䠮㻌䛂ᐙ᪘ᅾ䛃
"Skilled Labor"
䕕 㻌䠫㻌䛂⯆⾜䛃 䕕 㻌䠬㻌䛂␃Ꮫ䛃
"Designated
Designated Activities ( Researcher or IT engineer of a designated org)"
org)
䕕 䠭㻌䛂◊ಟ䛃
"Student"
Student
"Entertainer"
Entertainer
"Dependent"
䕕 㻌䠰䛂Ọఫ⪅䛾㓄അ⪅➼䛃
"Designated Activities(Dependent of EPA)"
䕕 䠰䛂ᐃఫ⪅䛃
"Spouse or Child of Permanent Resident"
"Long Term Resident"
䕕㻌㻌䛂㧗ᗘᑓ㛛⫋䠄䠍ྕ䜲䠅䛃
䕕㻌㻌䛂㧗ᗘᑓ㛛⫋䠄䠍ྕ䝻䠅䛃
䕕 䛂㧗ᗘᑓ㛛⫋䠄㻝ྕ䝝䠅䛃
"Highly Skilled Professional(i)(a)"
"Highly Skilled Professional(i)(b)"
"Highly Skilled Professional(i)(c)"
㻝㻞䚷ධᅜணᐃᖺ᭶᪥
Date of entry
ᖺ
᭶
᪥
Year
Month
Day
㻝㻠䚷ᅾணᐃᮇ㛫
"Technical
Technical Intern Training 㻔㻌㼕㻌㻕
㻔㼕㻕
䕕 䠮䛂≉ᐃάື䠄㻱㻼㻭ᐙ᪘䠅䛃
"Designated Activities (Dependent of Researcher or IT engineer of a designated org)"
"Spouse or Child of Japanese National"
䕕 㼅㻌䛂ᢏ⬟ᐇ⩦䠄䠍ྕ䠅䛃
"Trainee"
Trainee
䕕㻌䠮㻌䛂≉ᐃάື䠄◊✲άື➼ᐙ᪘䠅䛃
䕕 㻌䠰㻌䛂᪥ᮏே䛾㓄അ⪅➼䛃
"Journalist"
䕕 㻌䠨㻌䛂◊✲䠄㌿໅䠅䛃
䕕 䠪㻌䛂ᢏ⾡䞉ேᩥ▱㆑䞉ᅜ㝿ᴗົ䛃
"Researcher"
䕕 䠨䛂ሗ㐨䛃
"Religious Activities"
䕕 䠱㻌䛂䛭䛾௚䛃
Others
㻝㻟䚷ୖ㝣ணᐃ 
Port of entry
㻝㻡䚷ྠక⪅䛾᭷↓
Intended length of stay
᭷ 䞉 ↓
Accompanying persons, if any
Yes / No
㻝㻢䚷ᰝド⏦ㄳணᐃᆅ
Intended place to apply for visa
㻝㻣䚷㐣ཤ䛾ฟධᅜṔ
᭷ 䞉 ↓
Past entry into / departure from Japan
Yes / No
䠄ୖグ䛷䛄᭷䛅䜢㑅ᢥ䛧䛯ሙྜ䠅䚷(Fill in the followings when the answer is "Yes")
㻌ᅇᩘ
ᅇ
┤㏆䛾ฟධᅜṔ
ᖺ
᭶
time(s)
The latest entry from
Year
Month
㻝㻤䚷≢⨥䜢⌮⏤䛸䛩䜛ฎศ䜢ཷ䛡䛯䛣䛸䛾᭷↓㻌䠄᪥ᮏᅜእ䛻䛚䛡䜛䜒䛾䜢ྵ䜐䚹䠅
᭷ 䠄ලయⓗෆᐜ
㻌
᪥ 䛛䜙
ᖺ
᭶
᪥
Day
Year
Month
Day
to
Criminal record (in Japan / overseas)
䠅 䞉 ↓
Yes ( Detail:
㻝㻥䚷㏥ཤᙉไཪ䛿ฟᅜ࿨௧䛻䜘䜛ฟᅜ䛾᭷↓
᭷ 䞉 ↓
Departure by deportation /departure order
䠄ୖグ䛷䛄᭷䛅䜢㑅ᢥ䛧䛯ሙྜ䠅
(Fill in the followings when the answer is "Yes")
Yes / No
ᅇᩘ
ᅇ
)
┤㏆䛾㏦㑏Ṕ
time(s) The latest departure by deportation
/
No
ᖺ
᭶
᪥
Year
Month
Day
㻞㻜䚷ᅾ᪥ぶ᪘䠄∗䞉ẕ䞉㓄അ⪅䞉Ꮚ䞉඗ᘵጜጒ䛺䛹䠅ཬ䜃ྠᒃ⪅
Family in Japan (Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents
⥆䚷᯶
Ặ䚷ྡ
Relationship
Name
⏕ᖺ᭶᪥ ᅜ䚷⡠䞉ᆅ䚷ᇦ
Date of birth
Nationality/Region
ྠᒃணᐃ
໅ົඛ䞉㏻Ꮫඛ
Intended to reside
with applicant or not
Place of employment/school
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
㻌
㻌
䈜 㻞㻜䛻䛴䛔䛶䛿䠈グ㍕ḍ䛜୙㊊䛩䜛ሙྜ䛿ู⣬䛻グධ䛧䛶ῧ௜䛩䜛䛣䛸䚹䚷䛺䛚㻘䛂◊ಟ䛃䠈䛂ᢏ⬟ᐇ⩦䛃䛻ಀ䜛⏦ㄳ䛾ሙྜ䛿グ㍕୙せ䛷䛩䚹
Regarding item 20, if there is not enough space in the given columns to write in all of your family in Japan, fill in and attach a separate sheet.
addition,
t o , ta
takee note
ote tthat
at you aaree not
ot required
equ ed to fill in item
te 200 for
o app
applications
cat o s pe
pertaining
ta g to “Trainee”
a ee / “Technical
ec ca Intern
te Training”.
a g
In add
䠄ὀ䠅㻌⿬㠃ཧ↷䛾ୖ䠈⏦ㄳ䛻ᚲせ䛺᭩㢮䜢సᡂ䛧䛶ୗ䛥䛔䚹䚷Note : Please fill in forms required for application. (See notes on reverse side.)
ᅾ␃䜹䞊䝗␒ྕ
≉ูỌఫ⪅ド᫂᭩␒ྕ
Residence card number
Special Permanent Resident Certificate number
㻌
⏦ㄳே➼సᡂ⏝㻌䠎䚷䚷䠬䚷䠄䛂␃Ꮫ䛃䠅
ᅾ␃㈨᱁ㄆᐃド᫂᭩⏝
For applicant, part 2 P ("Student")
For certificate of eligibility
㻞㻝䚷㏻Ꮫඛ Place of study
㻔㻝㻕ྡ䚷⛠
㛵す኱Ꮫᅜ㝿ᩍ⫱䝉䞁䝍䞊䠄᪥ᮏㄒ䞉᪥ᮏᩥ໬ᩍ⫱䝥䝻䜾䝷䝮ㄒᏛ␃Ꮫ䝁䞊䝇䠅
Name of school
䛈㻡㻢㻠㻙㻤㻢㻤㻜
኱㜰ᗓ྿⏣ᕷᒣᡭ⏫㻟୎┠㻟␒㻟㻡ྕ
㻞㻞䚷ಟᏛᖺᩘ㻌䠄ᑠᏛᰯ䡚᭱⤊ᏛṔ䠅
㻔㻞㻕ᡤᅾᆅ
㻔㻟㻕㟁ヰ␒ྕ
Address
㻜㻢㻙㻢㻟㻢㻤㻙㻝㻝㻣㻠
Telephone No.
ᖺ
Total period of education (from elementary school to last institution of education)
㻞㻟䚷᭱⤊ᏛṔ㻌䠄ཪ䛿ᅾᏛ୰䛾Ꮫᰯ䠅
㻔㻝㻕ᅾ⡠≧ἣ
䕕 ༞ᴗ
Registered enrollment
Education (last school or institution) or present school
䕕 ᅾᏛ୰
Graduated
䕕 ኱Ꮫ㝔㻌䠄༤ኈ䠅
䕕 㧗➼Ꮫᰯ
䕕 ఇᏛ୰
In school
䕕 ኱Ꮫ
Master
㻔㻞㻕Ꮫᰯྡ
䕕 ᑓ㛛Ꮫᰯ
Junior college
䕕 ᑠᏛᰯ
Junior high school
Withdrawal
䕕 ▷ᮇ኱Ꮫ
Bachelor
䕕 ୰Ꮫᰯ
Senior high school
䕕 ୰㏥
Temporary absence
䕕 ኱Ꮫ㝔㻌䠄ಟኈ䠅
Doctor
Years
College of technology
䕕 䛭䛾௚㻌䠄
Elementary school
䠅
Others
㻔㻟㻕༞ᴗཪ䛿༞ᴗぢ㎸䜏ᖺ᭶
ᖺ
᭶
Date of graduation or expected graduation
Year
Month
Name of the school
㻞㻠䚷᪥ᮏㄒ⬟ຊ㻌䠄ᑓಟᏛᰯཪ䛿ྛ✀Ꮫᰯ䛻䛚䛔䛶᪥ᮏㄒᩍ⫱௨እ䛾ᩍ⫱䜢ཷ䛡䜛ሙྜ䛻グධ䠅
Japanese language ability (Fill in the followings when the applicant plans to study at advanced vocational school or vocational school
(except Japanese language))
䕕 ヨ㦂䛻䜘䜛ド᫂ Proof based on a Japanese language test
䠄䠍䠅ヨ㦂ྡ Name of the test
䠄䠎䠅⣭ཪ䛿Ⅼᩘ Attained level or score
䕕 ᪥ᮏㄒᩍ⫱䜢ཷ䛡䛯ᩍ⫱ᶵ㛵ཬ䜃ᮇ㛫 Organization and period to have received Japanese language education
ᶵ㛵ྡ
Organization
ᮇ㛫䠖
ᖺ
᭶
䛛䜙
ᖺ
Period from
Year
Month
to
Year
᭶ 䜎䛷
Month
䕕 䛭䛾௚
Others
㻞㻡䚷᪥ᮏㄒᏛ⩦Ṕ㻌䠄㧗➼Ꮫᰯ䛻䛚䛔䛶ᩍ⫱䜢ཷ䛡䜛ሙྜ䛻グධ䠅
Japanese education history (Fill in the followings when the applicant plans to study in high school)
㻌᪥ᮏㄒ䛾ᩍ⫱ཪ䛿᪥ᮏㄒ䛻䜘䜛ᩍ⫱䜢ཷ䛡䛯ᩍ⫱ᶵ㛵ཬ䜃ᮇ㛫
Organization and period to have received Japanese language education / received education by Japanese language
ᶵ㛵ྡ
Organization
ᮇ㛫䠖
ᖺ
᭶
䛛䜙
ᖺ
Period from
Year
Month
to
Year
᭶ 䜎䛷
Month
㻞㻢䚷ᅾ㈝䛾ᨭᘚ᪉ἲ➼ Method of support to pay for expenses while in Japan
㻔㻝㻕ᨭᘚ᪉ἲཬ䜃᭶ᖹᆒᨭᘚ㢠 Method of support and an amount of support per month (average)
䕕 ᮏே㈇ᢸ
෇
䕕 ᅾእ⤒㈝ᨭᘚ⪅㈇ᢸ
Self
Yen
Supporter living abroad
䕕 ᅾ᪥⤒㈝ᨭᘚ⪅㈇ᢸ
෇
Supporter in Japan
Yen
䕕 䛭䛾௚
෇
Others
Yen
䕕 ዡᏛ㔠
Scholarship
㻔㻞㻕㏦㔠䞉ᦠ⾜➼䛾ู Remittances from abroad or carrying cash
䕕 እᅜ䛛䜙䛾ᦠ⾜
෇
䕕 እᅜ䛛䜙䛾㏦㔠
Carrying from abroad
䠄ᦠ⾜⪅
Name of the individual
carrying cash
Yen
ᦠ⾜᫬ᮇ
Date and time of
carrying cash
Remittances from abroad
䠅 䕕 䛭䛾௚
Others
㻔㻟㻕⤒㈝ᨭᘚ⪅ Supporter
䐟Ặ䚷ྡ
Name
䐠ఫ䚷ᡤ
㟁ヰ␒ྕ
Address
Telephone No.
䐡⫋ᴗ㻌䠄໅ົඛ䛾ྡ⛠䠅
㟁ヰ␒ྕ
Occupation (place of employment)
䐢ᖺ䚷཰
Annual income
Telephone No.
෇
Yen
෇
Yen
෇
Yen
෇
Yen
෇
Yen
⏦ㄳே➼సᡂ⏝㻌䠏䚷䚷䠬䚷䠄䛂␃Ꮫ䛃䠅
ᅾ␃㈨᱁ㄆᐃド᫂᭩⏝
For applicant, part 3 P ("Student")
For certificate of eligibility
㻔㻠㻕⏦ㄳே䛸䛾㛵ಀ㻌䠄ୖグ㻔㻝㻕䛷ᅾእ⤒㈝ᨭᘚ⪅㈇ᢸཪ䛿ᅾ᪥⤒㈝ᨭᘚ⪅㈇ᢸ䜢㑅ᢥ䛧䛯ሙྜ䛻グධ䠅
Relationship with the applicant (Check one of the followings when your answer to the question 26(1) is supporter living abroad or Japan)
䕕ኵ
䕕ጔ
Husband
䕕∗
Wife
䕕 ඗ᘵጜጒ
䕕ẕ
Father
䕕 ♽∗
Mother
䕕 ♽ẕ
Grandfather
䕕 ུ∗㻌䠄఑∗䠅䞉ུẕ䠄఑ẕ䠅
Brother / Sister
Uncle / Aunt
䕕 ཭ே䞉▱ே䛾ぶ᪘
䕕 㣴∗
Grandmother
Foster father
䕕 ཷධᩍ⫱ᶵ㛵
䕕 㣴ẕ
Foster mother
䕕 ཭ே䞉▱ே
Educational institution
Friend / Acquaintance
䕕 ྲྀᘬ㛵ಀ⪅䞉⌧ᆅ௻ᴗ➼⫋ဨ
Relative of friend / acquaintance
Business connection / Personnel of local enterprise
䕕 ྲྀᘬ㛵ಀ⪅䞉⌧ᆅ௻ᴗ➼⫋ဨ䛾ぶ᪘
䕕 䛭䛾௚㻌䠄
Relative of business connection / personnel of local enterprise
䠅
Others
㻔㻡㻕ዡᏛ㔠ᨭ⤥ᶵ㛵㻌䠄ୖグ㻔㻝㻕䛷ዡᏛ㔠䜢㑅ᢥ䛧䛯ሙྜ䛻グධ䠅
Organization which provide scholarship (Check one of the following when the answer to the question 26(1) is scholarship)
䕕 እᅜᨻᗓ
䕕 ᪥ᮏᅜᨻᗓ
Foreign government
䕕 ᆅ᪉බඹᅋయ
Japanese government
Local government
䕕 බ┈♫ᅋἲேཪ䛿බ┈㈈ᅋἲே㻌䠄
䠅 䕕 䛭䛾௚㻌䠄
Public interest incorporated association /
Public interest incorporated foundation
Plans after graduation
㻞㻣䚷༞ᴗᚋ䛾ணᐃ
䕕 ᖐ䚷ᅜ
䠅
Others
䕕 ᪥ᮏ䛷䛾㐍Ꮫ
Return to home country
䕕 ᪥ᮏ䛷䛾ᑵ⫋
Enter school of higher education in Japan
䕕 䛭䛾௚㻌䠄
Find work in Japan
䠅
Others
㻞㻤䚷ᮏ㑥䛻䛚䛡䜛⏦ㄳே䛾┘ㆤே䠄㏻Ꮫඛ䛜୰Ꮫᰯཪ䛿ᑠᏛᰯ䛾ሙྜ䛻グධ䠅
Actual guardian in Japan䚷( Fill in the following if the applicant is to study at a junior high school or elementary school )
㻔㻝㻕Ặ䚷ྡ
㻔㻞㻕ᮏே䛸䛾㛵ಀ
Name
Relationship with the applicant
ཷධᩍ⫱ᶵ㛵⫋ဨ
㛵す኱Ꮫᅜ㝿ᩍ⫱䝉䞁䝍䞊䠄᪥ᮏㄒ䞉᪥ᮏᩥ໬ᩍ⫱䝥䝻䜾䝷䝮ㄒᏛ␃Ꮫ䝉䞁䝍䞊䠅
䛈㻡㻢㻠㻙㻤㻢㻤㻜㻌኱㜰ᗓ྿⏣ᕷᒣᡭ⏫㻟୎┠㻟␒㻟㻡ྕ
㟁ヰ␒ྕ
ᦠᖏ㟁ヰ␒ྕ
㻜㻢㻙㻢㻟㻢㻤㻙㻝㻝㻣㻠
㻔㻟㻕ఫ䚷ᡤ
Address
Telephone No.
Cellular Phone No.
㻞㻥䚷⏦ㄳே䠈ἲᐃ௦⌮ே䠈ἲ➨䠓᮲䛾䠎➨䠎㡯䛻つᐃ䛩䜛௦⌮ே
Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.
㻔㻝㻕Ặ䚷ྡ
㻔㻞㻕ᮏே䛸䛾㛵ಀ
Name
Relationship with the applicant
㻔㻟㻕ఫ䚷ᡤ
Address
㟁ヰ␒ྕ
ᦠᖏ㟁ヰ␒ྕ
Telephone No.
Cellular Phone No.
௨ୖ䛾グ㍕ෆᐜ䛿஦ᐇ䛸┦㐪䛒䜚䜎䛫䜣䚹
⏦ㄳே䠄௦⌮ே䠅䛾⨫ྡ䠋⏦ㄳ᭩సᡂᖺ᭶᪥
ὀ ព
I hereby declare that the statement given above is true and correct.
Signature of the applicant (representative) / Date of filling in this form
ᖺ
᭶
᪥
Year
Month
Day
⏦ㄳ᭩సᡂᚋ⏦ㄳ䜎䛷䛻グ㍕ෆᐜ䛻ኚ᭦䛜⏕䛨䛯ሙྜ䠈⏦ㄳே䠄௦⌮ே䠅䛜ኚ᭦⟠ᡤ䜢ゞṇ䛧䠈⨫ྡ䛩䜛䛣䛸䚹
Attention In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant
(representative) must correct the part concerned and sign their name.
䈜䚷ྲྀḟ⪅ Agent or other authorized person
㻔㻝㻕Ặ䚷ྡ
Name
㻔㻟㻕ᡤᒓᶵ㛵➼
㻔㻞㻕ఫ䚷ᡤ
Address
Organization to which the agent belongs
㟁ヰ␒ྕ
Telephone No.