2012 AO April Entry (Overseas) / / <Office Use Only>
School of International Liberal Studies,
Waseda University
How to Complete This Form
* Type or Write in English in a black ink. * A non-refundable application fee must accompany this application. See section 11. * Ensure that you complete the checklist and sign the declaration. See sections 9 and 13.
Section 1 / Personal Details
* Type or Write in a black ink using BLOCK LETTERS (as written in your passport).
FAMILY NAME:
* full legal name
GIVEN NAME:
* full legal name
MIDDLE NAME:
* full legal name
NAME in Chinese characters: * If any / NAME in KATAKANA:
* If any
Date of Birth: / Year: / Y / Y / Y / Y / Month: / M / M / Date: / D / D / Gender:
* Check □✔ one. / Male: / M / Female: / F
CURRENT ADDRESS * In English
Country/ Region of Citizenship:
Do you have a Japanese visa? / No / Yes
If "Yes", please specify:
* If available, write it in Chinese characters / Date of expiry: / Y / Y / Y / Y / M / M / D / D
What is your first language? * Check □✔ one.
English / E / Japanese / J / Other(specify)
Postcode/ Zip: / Country/ Region: / * If English is not your first language, indicate the number of years of English instruction you have received: / years
Telephone: / *(Country Code, Area Code, Local Code) / < Study Plan > Check □✔ one.
*Refer to Admission Guide, Step 1-9 Study Plan. Then, be sure to choose one. / Study Plan 1
FAX: / *(Country Code, Area Code, Local Code) / Study Plan 2
Mobile: / *(Country Code, Area Code, Local Code) / < Mailing Address > Check □✔ one.
* Specify the mailing address at which you would like to receive the result. / CURRENT ADDRESS:
E-mail: *mandatory / PERMANENT HOME ADDRESS:
OTHER ADDRESS:
PERMANENT HOME ADDRESS * If same as Current Address, write "As above" / OTHER ADDRESS * In English *If any
Postcode/ Zip: / Country/ Region: / Postcode/ Zip: / Country/ Region:
Telephone: / *(Country Code, Area Code, Local Code) / Telephone: / *(Country Code, Area Code, Local Code)
FAX: / *(Country Code, Area Code, Local Code) / FAX: / *(Country Code, Area Code, Local Code)
Mobile: / *(Country Code, Area Code, Local Code) / Mobile: / *(Country Code, Area Code, Local Code)
Section 2 / Photograph
Attach Your
Color Photograph
(4cm×3cm) / Photo CARD
Application for
2012 AO April Entry (Overseas) / School of International Liberal Studies
Waseda University
* Taken on or after July 1st, 2011.
* Print your name on the back of the photograph.
* 4cm long and 3cm wide.
* Borderless and taken against a plain background.
* Look straight ahead with your head uncovered. / FAMILY NAME: / <Office Use Only>
GIVEN NAME:
MIDDLE NAME:
<Office Use Only>
Section 3 / Educational Background
* List in English, in chronological order, all schools attended starting from primary school
Location of School / Name of School / Period of Attendance
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
City: / Country / Region: / Year: / Month: / ～ / Year: / Month:
Date of High School Graduation: / Year / Y / Y / Y / Y / Month / M / M / Date: / D / D / Graduated or Expected:
Check □✔ one. / Graduated: / Expected:
Date of High School Equivalency Examination / Year / Y / Y / Y / Y / Month / M / M / Date: / D / D / Total Period of Education: / Years Months
* e.g.) GED(USA), Certificate for Students Achieving the Proficiency Level of Upper Secondary School Graduates(Japan), etc.
Section 4 / Test Information
* Please write your results in the following tests and enclose the original score card with this application form.
English Proficiency
Date Taken (Year / Month): / Score: / Score Report to Be Directly Sent from Institution:
* Check □✔, in case. / Date Taken (Year / Month): / Score:
TOEFL (iBT) / Year / Y / Y / Y / Y / Month / M / M / TOEIC: / Year / Y / Y / Y / Y / Month / M / M
TOEFL (CBT) / Year / Y / Y / Y / Y / Month / M / M / GEPT: / Year / Y / Y / Y / Y / Month / M / M
TOEFL (PBT) / Year / Y / Y / Y / Y / Month / M / M / EIKEN: / Year / Y / Y / Y / Y / Month / M / M
IELTS: / Year / Y / Y / Y / Y / Month / M / M
University Entrance Qualification Examination
SAT Reasoning Test / Date Taken: / Year: / Y / Y / Y / Y / Month: / M / M / Directly Sent From Institution:
* Check □✔, in case.
Critical Reading: / Math: / Writing: / Total:
ACT / Date Taken: / Year: / Y / Y / Y / Y / Month: / M / M / Score (Composite) / Directly Sent From Institution:
* Check □✔, in case.
International Baccalaureate / Date Taken: / Year: / Y / Y / Y / Y / Month: / M / M / Score (Total) / Directly Sent From Institution:
* Check □✔, in case.
* If you have taken other test: ex) GCE-A level, GAO-KAO, Korean CSAT, Ontario/BC Provincial etc, write your results below.
Test Name / Country / Region / Date Taken (Year / Month): / Score
Other Tests / Year: / Y / Y / Y / Y / Month: / M / M
Year: / Y / Y / Y / Y / Month: / M / M
◆(1) For those who are scheduled to take the national standardized test (Korean CSAT, Thai O-Net, Australian standardized test or New Zealand's NCEA Level 3) etc, and to graduate from your school, check□✔ and write the following information.
I cannot submit the national standardized test result in time since it comes out after my application.
Test Name / Country / Region / Date to Be Taken (Year / Month):
Year: / Y / Y / Y / Y / Month: / M / M
◆(2) If the country or region where you are receiving or have received your education has no national standardized test for assessing your qualification to enter university, check □✔ and write the following information.
I cannot submit the national standardized test result / Country / Region
<Office Use Only>
Section 5 / Plans
* Please write about BOTH topics.
TOPIC No. 1 / Describe what you plan to study for 4 years at SILS, explaining the areas of study you intend to focus on and giving specific reasons. (within 200 words)
Description
TOPIC No. 2 / Describe how you see your future path after graduation from SILS. (within 200 words)
Description
<Office Use Only>
Section 6 / Academic Honors and Personal Activities
* If you would like to tell us your academic honors or personal activities after graduating from junior high school, choose up to three honors/activities as you think best in order. Describe them in the following given spaces and enclose a photocopy of any proof documents. Indicate the reference No. on each document to certify. (within 150 words each)
Ref. No. / Name of Honor / Activity
1. / Date Taken
(Year/ Month)
Description
Ref. No. / Name of Honor / Activity
2. / Date Taken
(Year/ Month)
Description
Ref. No. / Name of Honor / Activity
3. / Date Taken
(Year/ Month)
Description
Section 7 / Experience of Studying Abroad
* If you have some experience of studying abroad after graduating from junior high school, describe it and enclose a photocopy of your certificate of school and transcript. Indicate the reference No. on each document to certify.
Ref. No. / Location of School / Name of School / Period of Attendance
1. / City / Country / Region / Year: / Month: / ～ / Year: / Month:
2. / City / Country / Region / Year: / Month: / ～ / Year: / Month:
3. / City / Country / Region / Year: / Month: / ～ / Year: / Month:
4. / City / Country / Region / Year: / Month: / ～ / Year: / Month:
Page - 1 -
<Office Use Only>Section 8 / Interview Questionnaire / Section 11 / Screening Fee
* Be sure to choose one or two among the following scheduled interviews, and check □✔. / * A non-refundable Screening Fee must be paid with each application form submitted. Applicants will not be processed unless accompanied by the Screening Fee. Complete this section and check □✔ one carefully. For more details refer to the admission guide, [Step 2-2: how to pay for Screening Fee]
Place / ☑ / 1st Batch / ☑ / 2nd Batch
Tokyo
(Waseda University) / October 22 (SAT), 2011 / November 26 (SAT), 2011 / I paid from outside Japan. I attach a copy of my remittance form to the Application Form and enclose it with other materials.
October 29 (SAT), 2011 / December 3 (SAT), 2011 / I paid from within Japan at a convenience store. I paste the "Certificate of Payment of the Screening Fee" on the following space.
Bangkok
(Thailand) / October 29 (SAT), 2011 / December 3 (SAT), 2011 / <Only Those who Make Payment in Japan>
Attach your "Certificate of Payment of the Screening Fee"
Beijing
(China) / October 22 (SAT), 2011 / December 3 (SAT), 2011
Bonn
(Germany) / October 29 (SAT), 2011 / November 26 (SAT), 2011
Portland, OR
(USA) / October 21 (FRI), 2011 / December 2 (FRI), 2011 / I am non-Japanese and reside outside Japan. Acquaintances in Japan have paid the fee by the money transfer form designated by the School. I attach the "Certificate of Payment of the Screening Fee" and enclose it with other materials.
Seoul
(Korea) / October 22 (SAT), 2011 / November 26 (SAT), 2011 / I have attached and submitted together with my application form the "Application Form for a Screening Fee Waiver 2012 WASEDA University" and thus request to be exempted from the screening fee under the system that exempts applicants from designated countries.
Shanghai
(China) / October 29 (SAT), 2011 / November 26 (SAT), 2011 / Section 12 / Questionnaire (For statistical purpose only)
Singapore / October 22 (SAT), 2011 / November 26 (SAT), 2011 / * To be completed by all applicants. We would be grateful if you let us know the following questions.
1) How did you find out about the SILS? Please check □✔ one box only.
Taipei
(Taiwan) / October 29 (SAT), 2011 / November 26 (SAT), 2011 / Visiting WASEDA University Staff Member / WASEDA University/SILS Website
Others
*specify / Date: Place: / Date: Place: / Graduate/s of WASEDA University / Other Website
* specify ( )
Section 9 / Check List (Application Documents) / Advertisement in Newspaper
/ Magazine / WASEDA University Information Session
* specify place ( )
* Complete the following checklist before submitting and include original or certified copies of the following documents with your application. / WASEDA University Representative / Open Campus at WASEDA
Yes / No / ①: Application Form / Family / Friends / Education Fair
Yes / No / ②: English Essay / Your High School / Other * specify ( )
Yes / No / ③: Document to Prove Your Applicant Qualification / 2) Please list any other schools of Waseda or universities you are applying for, or intend to apply for, if any.
( )
Yes / No / ④: Academic Transcript / Section 13 / Declaration and Signature
Yes / No / ⑤: Certificate of Results of University Entrance Qualification Examination(s) and Other Standardized Tests / * Once you have completed all previous sections, read this section (Declaration and Signature) below and sign to indicate you agree with its terms;
Yes / No / ⑥: English / Japanese Translation of ③・④・⑤ above Notarized by an Embassy or Another Appropriate Office / 1. I declare that the information provided by me is true and complete in every particular.
Yes / No / ⑦: English Proficiency Test Score / 2. I acknowledge that all documents submitted become the property of WASEDA University and will not be returned.
Yes / No / ⑧: Letter to Explain in English the Reason Why You Are Unable to Submit of ④・⑤・⑦ above. / 3. I acknowledge that the provision of incorrect information or the withholding of relevant information relating to my application, including academic transcripts, might invalidate my application and that WASEDA University may withdraw an offer of a place or cancel my enrollment in consequence.
Yes / No / ⑯: Certificate of Items Stated in the Alien Register or Copies of Both Side of the Alien Registration Card
* if you are non-Japanese and reside in Japan. / 4. I understand that WASEDA University reserves the right to inform other tertiary institutions if any of the material presented to support my application is found to be false.
Section 10 / Check List (COE Documents) / 5. I consent to any educational institution at which I have previously been a student and/or my current or any past employer, providing WASEDA University with information which that institution holds about me for the purpose of WASEDA University verifying my grades and/or qualifications or experience.
* Check □✔ one.
I desire to have SILS as my proxy to obtain the "Certificate of Eligibility (COE)" from the Tokyo Immigration Bureau of the Ministry of Justice. / Yes / No / 6. (In the case that the applicant asks Waseda University to submit an application for a Certificate of Eligibility on the applicant's behalf) I acknowledge that WASEDA University will not be held responsible for any disadvantages incurred should the Ambassador/Consul of Japan decides to delay or deny my request for a student visa due to a problem with the documents I submitted.
* If "Yes", complete the following checklist before submitting and include the following documents with your application.
Yes / No / ⑨: Statement of Financial Resources / 7. (In the case that the applicant does not ask WASEDA University to submit an application for a Certificate of Eligibility on the applicant's behalf) I acknowledge that WASEDA University will not be held responsible for any disadvantages incurred should the Ambassador/Consul of Japan decides to delay or deny my request for a student visa.
Yes / No / ⑩: Certificate of the Deposit Balance of a Bank Account
Yes / No / ⑪: Agreement for Defraying Expenses / 8. I declare that I will be able to abide by the statutes, regulations and policies on admission, fees payments and fee refunds of WASEDA University.
Yes / No / ⑫: Application for a Certificate of Eligibility (COE) / 9. I have read and understood the above conditions and accept them in full.
Yes / No / ⑬: Personal History / Student Signature :
Yes / No / ⑭: Copy of Your Passport
* if you have one / FULL NAME :
* PRINT as written in your passport
Yes / No / ⑮: Copy of Your Resident Card
* if you are Korean / Date: / Year / Y / Y / Y / Y / Month / M / M / Date / D / D
* Do NOT change the format so that the Application Form fits in the given 5 pages.