The GlaxoSmithKline International ScholarshipCharitable Trust Fund

Application Form for2009

Information provided in this application form shall be acquired and used by the steering committee and administrator of this charitable trust within the scope necessary to select scholarship recipients and manage the charitable trust. If awarded with the scholarship, I agree that personal information shall be provided to the competent government authorities and announced to the general public.

Name: / (Surname) / (First name) / PHOTOGRAPH
Home Address & Contact Info: / Telephone: E-mail:
Male/Female: / Marital status:
Date of Birth: / Age:
Specialised Subject: / Present Academic Position:
School Address:
Telephone: E-mail:
Academic career (describe fully since your graduation from high school, including education abroad, if any):
Career after university:
Details of your main subject(s) of study at university,including degree(s), with dates:
Name of the person (with his/her title, degree,etc.) writingthe letter of recommendation(to be in confidential form)in support of your application. Please attach it with this application.
Name,address,tel/fax number and relation of the contact person during the scholarship term:
Details of other scholarships or awards to which you are applying, if any:
Proposed future profession in Japan:
Hobbies:
Please describe your major research that you have undertaken in the past, regardless of whether in English or in Japanese or another language. Please attach a copy of your research.
Describe fully your proposed subject of study or research and give the name of the faculty, university, and instructor under whom you would like to study.
Please explain why you wish to study in Britain.
State any qualifications to prove your English ability (IELTS, STEP, TOEFL scores etc.):
Date and signature of applicant:
Instructions
  1. Application must be completed in both English and Japanese.
  2. Application must be accompanied by the following documents (accepted in Japanese):
(1)Copy of personal identification (driver’s licence, health insurance card, etc.).
(2)Copy of your university academic transcript and graduation certificate.
(3)Letter of recommendation (to be sent in confidential form). / (4)Copy of the letter of acceptance from the British university where you wishto study.
(5) Certificate to prove your English proficiency.
3. Please read thoroughly the separate description of the scholarship.
4. Applicant may be requested for an interview (time and place to be decided)

Based on the law to protect personal information (Law No. 57. 30 May 2003), the trustee shall use the applicant’s personal information only within the scope necessary to undertake charitable trust activities.