[For International Students] Procedure of the Application for Tuition Fee Exemption Exemption of Tuition Fee for Second Term 2012 Application for Tuition Fee Exemption is for those who have financial difficulty in paying Tuition Fee; in case application is permitted by the screening, all or half the amount of tuition fee is to be exempted. The screening is done every term, first and second term upon application. 1. Qualification (1) One who has an outstanding academic record, and fairly has financial difficulty in paying Tuition Fee. (2) One who him/herself has been damaged by natural disaster in JAPAN within one year so that making Tuition Fee payment is difficult. * If you want to know the academic standard for application, please contact Division of Student Affairs. Those who correspond to any of the conditions below cannot apply. (1) Those who have already paid tuition fee for this year, (2) Those who have been held back. (3) International students who receive scholarship from Government of Japan or of home countries. 2. Application Period (Documents must be submitted/ arrive during the period below) August 20 (Mon) 2012 – September 7 (Fri) 2012 * Application AFTER the period is NOT accepted for any reason. In case you cannot make the application during the period, please ask the section in charge beforehand. 3. Application Please bring the documents directly to Division of Student Affairs (open from Monday to Friday, 9:00 am- 17:00 pm). 4. Documents Required (1) Application Form for Tuition Fee Exemption (Second Term) (2) Form for Family Condition (Designated Form) -The data in the form should be that at the time of application. (Designated Form) -Space within the bold lines is for office use. Please don’t fill in. -For the space for ‘family members except students’, please fill in the data of only those who live in JAPAN. -Space for ‘family member(s) in school except you’ should be filled in if your family member in Japan is a student; Please circle each applicable number and write the correct name of school. (3) Certificate of Salary (Designated Form) or Copy of a `Gensen-Tyoshu-Hyo’, withholding slip 2011 ONLY those who have a part time job at the time of application should submit. (4) Recommendation Letter from Supervisor (Designated Form) Please ask your current or prospective supervisor to make it for you. 5. Notice of the Result of Screening Result of the screening if your application for Tuition Fee Exemption is to be notified at Division of Student Affairs during December 2012. In case your application is not permitted, you will be asked to make the payment by the designated deadline with the payment sheet handed to you; commission fee is charged additionally upon payment. If you have any questions regarding applications, please contact Division of Student Affairs. 家　庭　調　書　Form for Family Condition [Sample] 〔for Tuition Fee〕学　籍　番　号 Student ID Number （Name in Katakana ） 1 e x c e p t S T U D E N T S 1 3 8 1 2 3 4 Name of Applicant F A M I L Y Relatio nship 氏　名 Name WIFE NAGAOKA HANAKO Relatio nship 氏　名 Name Age ナガオカ　タロウ通学 1．自宅通学 NAGAOKA TARO 区分 2．自宅外通学 Occupation and Name of Institution/Company 給与所得以外の所得千円 30 HOUSEWIFE M E M B E R S c h o o l Age NAGAOKA HAJIME 20 １．国立２．公立３．私立１．国立２．公立３．私立 ) １．国立２．公立３．私立 i Y n １．国立２．公立３．私立 O U 在　学　学　校 Name of School 設置区分 ( M BROE THER M B F E a e R m x i c S l e y p t 給与所得千円本人 You 父 Father 母 Mother WIFE BROTHER 千円千円千円千円千円千円 400 Salary ※　F A M I L Y 特別控除関係 1．自宅通学 2．自宅外通学 1．自宅通学 2．自宅外通学 1．自宅通学 2．自宅外通学 1．自宅通学 2．自宅外通学 Your Scholarship Condition Scholarship you will award FY 2012 (if any) 300 ※Please fill in the TOTAL income amount from Jan. - Dec. of the previous year, Name disregarding figures below one thousand yen (ex. Income of 20,000 yen should be written as 20). Income ( JASSO except Salary 80,000 Other Income I N C O M E 通学区分 1.Elementary School 学校名 Name of school 2.Junior HighSchool ○○ University 3.High School （　1　Year） 4.University 5.Other 1.Elementary School 学校名 Name of school 2.Junior HighSchool 3.High School （　Year） 4.University 5.Other 1.Elementary School 学校名 Name of school 2.Junior HighSchool 3.High School （　Year） 4.University 5.Other 1.Elementary School 学校名 Name of school 2.Junior HighSchool 3.High School （　Year） 4.University 5.Other ) yen/month Scholarship Period Occasional Income Total 400 300 2012 年　4 月より ※　Salary: salary for regular/part time job, directors' remuneration, aid allowance from yy mm Income except Salary: income for trade, farming, forestry, fishery, etc. Other Income: Income as rent, interest, allotment, etc. 受給額（年額）　千円 Occasional Income: retirement money, insurance money etc. Please fill in the TOTAL income amount from Jan. - Dec. of the previous year, disregarding figures below 1,000 yen. 母子・父子世帯父無　死亡・離婚・別居　（　年　月）母無　死亡・離婚・別居　（　年　月）障害者のいる世帯続柄　（　）手帳番号　（　続柄　（　）手帳番号　（　長期療養者のいる世帯続柄　（　）療養期間　年　月から続柄　（　）療養期間　年　月から主たる家計支持者別居住居・光熱水費等　の世帯））人合計　千円合計　千円千円火災・風水害・盗難等の被害年月日・内容　（平成　年　月　日）被害を受けた世帯被害額　千円 ※　Space within ０　：該当せず１　：該　当家族数人学力０：不適格１：適　格生活保護１：有　り独立生計者１：有　り申請区分１：一般　２：家計３：学力　４：事由合計　千円５：事情（家計支持者死亡）６：事情（災害）７：事情（その他） is for office use. Please don't fill in. ※　Space for family members should be filled in the data of only those who live in JAPAN. 年　月　日 (yy, mm, dd) 平成２４年度　後期分授　業　料　免　除　願 Application for Tuition Fee Exemption 長岡技術科学大学長　殿 To President of Nagaoka University of Technology grade 所属課程 Major 専攻　第　学年 Period of Enrollmen （西暦）年月学籍番号 Student Number 本人氏名（自署） Name 同住所〒 Address 携帯電話番号 Phone Number 保証人氏名（自署）〒同住所 No need to fill in 電話番号下記により、授業料免除を御許可くださるよう保証人の連署をもって申請します。 I apply for Tuition Fee Exemption as follows; 記理由（申請者本人が具体的に記入のこと） Reason for Application (to be written concretely) 〔授業料免除用 for Tuition Fee〕家　庭　調　書 Form for Family Condition 学　籍　番　号 Student ID Number （Name in Katakana ）通学 1．自宅通学区分 2．自宅外通学 Name of Applicant e x c e p t S T U D E N T S F A M I L Y Relatio nship 氏　名 Name Age Relatio nship 氏　名 Name Age Occupation and Name of Institution/Company 給与所得以外の所得千円 M E M B E R S c h o o l 在　学　学　校 Name of School 設置区分１．国立２．公立３．私立学校名 Name of school （　Year）１．国立２．公立３．私立学校名 Name of school （　Year）１．国立２．公立３．私立学校名 Name of school （　Year）１．国立２．公立３．私立学校名 Name of school （　Year） ( M E M B F E a e R m x i c S l e y ) p t 給与所得千円 i Y n O U 本人 You 父 Father 母 Mother 千円千円千円千円千円特別控除関係 2．自宅外通学 1．自宅通学 2．自宅外通学 1．自宅通学 2．自宅外通学 1．自宅通学 2．自宅外通学 Scholarship you will award FY 2012 (if any) ※Please fill in the TOTAL income amount from Jan. - Dec. of the previous year, Name disregarding figures below one thousand yen (ex. Income of 20,000 yen should be written as 20). Income ( except Salary Other Income I N C O M E 1．自宅通学 Your Scholarship Condition 千円 Salary ※　F A M I L Y 通学区分 1.Elementary School 2.Junior HighSchool 3.High School 4.University 5.Other 1.Elementary School 2.Junior HighSchool 3.High School 4.University 5.Other 1.Elementary School 2.Junior HighSchool 3.High School 4.University 5.Other 1.Elementary School 2.Junior HighSchool 3.High School 4.University 5.Other yen/month Scholarship Period Occasional Income Total ※　Salary: salary for regular/part time job, directors' remuneration, aid allowance from Income except Salary: income for trade, farming, forestry, fishery, etc. Other Income: Income as rent, interest, allotment, etc. Occasional Income: retirement money, insurance money etc. Please fill in the TOTAL income amount from Jan. - Dec. of the previous year, disregarding figures below 1,000 yen. 母子・父子世帯父無　死亡・離婚・別居　（　年　月）母無　死亡・離婚・別居　（　年　月）障害者のいる世帯続柄　（　）手帳番号　（　続柄　（　）手帳番号　（　長期療養者のいる世帯続柄　（　）療養期間　年　月から続柄　（　）療養期間　年　月から主たる家計支持者別居住居・光熱水費等　の世帯））０　：該当せず１　：該　当人年　月より yy mm 受給額（年額）　千円家族数学力合計　千円生活保護独立生計者合計　千円千円火災・風水害・盗難等の被害年月日・内容　（平成　年　月　日）被害を受けた世帯被害額　千円 ※　Space within ) 人０：不適格１：適　格１：有　り１：有　り申請区分１：一般　２：家計３：学力　４：事由合計　千円５：事情（家計支持者死亡）６：事情（災害）７：事情（その他） is for office use. Please don't fill in. ※　Space for family members should be filled in the data of only those who live in JAPAN. For Tuition Fee アルバイト等収入証明書 Certificate of Salary 長岡技術科学大学 Nagaoka University of Technology 所属課程・専攻 Major 年 Grade 氏名 Name 上記の者の賃金支払（見込）額等は、下記のとおりであることを証明します。記１．賃金：２．期間：３．日数：平成年円（日額・月額・年額）年月日～日／月月日所在地代表者名（会社名）印 ○ 平成年月日４．本人の経済的状況等私費外国人留学生授業料免除推薦書 Recommendation Letter for Tuition Fee Exemption 長岡技術科学大学長殿所属（系）職名推薦者氏名下記により、平成２４年度後期分授業料免除について推薦します。記１．推薦する学生の課程（専攻）、学年、氏名所属氏名２．本学入学前の経歴等年月３．推薦理由課程・専攻年５．その他特記事項等日入国