Examinee's No.

Application Form for Admission for Twinning Program in International Master’s Degree Program

Graduate School of Engineering, Toyohashi University of Technology

for the Academic Year 2018(EntranceinOctober2018)

1. Personal details
NameinFull / Paste your photographor digital image taken within the past 3 months. (30mm×40mm)
(Please write your name exactly as it appears on your passport)
Chinese character,
if any
Sex / □Male / □Female
Marital status / □Single / □Married
Dateofbirth
(yyyy/mm/dd) / Nationality
Current resident address / Zip code(〒):
E-mail address / Phone number
(with country code)
Your status in October 2018 / □Japanese Government Scholarship Student* □JICA student □Self-financed student
*Certificate of Japanese Government Scholarship should be attached.
2. Academic preference
Preferred Department
(Choose one of five courses) / □Mechanical Engineering
□Electrical and Electronic Information Engineering
□Computer Science and Engineering
□Environment and Life Sciences
□Architecture and Civil Engineering
Supervisor at TUT
(You must obtain his/her approval and have enough discussion on your research plan beforehand)
3.English Proficiency
Is English your first language?
□Yes □No □No, but I have completed English-based degree program*
*English-based degree program means all lectures, examinations, reports and thesis and any other instructions given to students during your degree program are provided in English only.
If No, what is your first language? ( )
English language proficiency test (TOEFL, IELTS etc) / Overall score / Date taken(yyyy/mm/dd)
4. Educational background
Name of institution / Year(s)of study / From / To / Diploma or Degree awarded, Skipped years/levels*
yyyyy/mm / yyyy/mm
Elementary Education /
Secondary Education
(Junior High School) /
Upper Secondary School
(High School) /
Higher Education
(University, Undergraduate Level) /
Graduate Level /
Your home institution:
□Ho Chi Minh City University of Technology（HCMUT）
□Institut Teknologi Bandung（ITB）
□Hasanuddin University（UNHAS）
□Northeastern University（NEU）
□ Universiti Sains Malaysia（USM） / Total years of schooling mentioned above
（全学校教育修学年数）
Years / Months
Notes
1)Preparatory education for university admission is included in secondary education.
2) Any school years or levels skipped should be indicated in the column of Diploma or Degree Awarded, Skipped years/Levels (Example: Graduated high school in 2 years), and an official document from the institution which applicants graduated attesting to this should be attached.
3)If you attended multiple schools at the same level of education due to moving house or readmission to university, then write the schools in the same column and include the number of years of study and current status for each school.
4) Calculate and write the total number of years studied based on duration as a student (including extended leave such as summer vacation)
5. Work experience（if any）
From/To
(yyyy/mm－yyyy/mm) / Nameof institution/company / Position / Job title / Type of work
6. Declaration
I confirm that the information I have given in this form is true, complete and accurate and no information requested or other material information has been omitted. I have read the notes of application procedure, in particular those relating to this section. I understand what they say and I agree to abide by the conditions set out there. I acknowledge that the information on this form will be used in accordance with Japanese data protection rules and will be used to form the basis of my student record. I give my consent to the processing of my data by the university. I accept that, if I do not fully comply with these requirements the university shall have right to cancel my application and I shall have no claim against the university in relation thereto.
Full name in block capital and signature / Date:
Signature