APPLICATION FORM KEIO SCHOLARSHIP FOR ITALIAN RESEARCHER/STUDENT 慶應奨学金留学生願書 Write your name and nationality in block letters on the back of the photo and paste your photograph taken within the past 6 months. (3cm x 4cm) x 3 INSTRUCTION （記入上の注意） 1. Application should be typewritten or written in Roman block letters. (記入はタイプ又はローマ字を用いること) 2. Year should be written in the Anno Domini system. (年号はすべて西暦を用いること) 3. Proper nouns should be written in full, and not be abbreviated. (固有名詞はすべて正式な名称とし、一切省略しないこと) 1. Name in full; in native language (姓名－自国語) In Roman block letters , (Family name) , (First name) , (ローマ字) In katakana (if any) (Family name) (カタカナ) (Family name) , (First name) , Year 19 (年) (Middle name) , (First name) 2. Date of birth(生年月日) Age (年齢) (Middle name) (Middle name) 3. Nationality Month (月) Day (日) (国籍) 4. Present address (現住所) 5. telephone and fax numbers(電話およびファックス番号) (tel) (fax) 6. Email address (電子メールアドレス) 7. Permanent address(本籍) 8. Housing assistance from Keio YES NO, I will find housing on my own, and my address and contacts in Tokyo will be: Address: Phone: Sex □ Male(男) □ Female(女) Marital status □ Single(未婚) □ Married(既婚) 9. Educational background (学歴) * Statement for Columns 9 – 13 must be typewritten in block letters and additional sheets of paper may be attached for these columns. （9-13番の問いについてはタイプ又は楷書によるものとし、別紙に記入してもよい。） Diploma Year and Month of enMajor or degree Name and Address of School example trance and completion subject awarded (学校名および所在地) (入学および卒業年月) (専攻科目) (学位･資格) Higher Education Elementary Education (初等教育) Elementary School (小学校) Secondary Lower Education School (中等教育) (中学) Upper School (高校) Higher Education (高等教育) Undergraduate Level (大学) Graduate Level (大学院) Graduate School of Letters, Keio University 2-15-45 Mita, Minato-ku, Tokyo 108-8345 JAPAN Name (学校名) Location (所在地) Name (学校名) Location (所在地) Name (学校名) Location (所在地) Name (学校名) Location (所在地) Name (学校名) Location (所在地) 1980.4 – 1982.3 Women’s History M.A. in Letters, 1982.3 from (入学) to (卒業) from (入学) to (卒業) from (入学) to (卒業) from (入学) to (卒業) from (入学) to (卒業) 10. Employment record. Begin with the most recent employment, if applicable. (職歴) Name and address of organization Period of employment Position Type of work (勤務先および所在地) (勤務期間) (役職名) (職務内容) Kyoto University somewhere in Kyoto, JAPAN From 1990.4 To present Associate Professor Research/ Education from to from to from to from to 11. Field of study specialized in the past: Describe in detail and as concretely as possible. (過去に専攻した専門分野 ― できるだけ具体的に詳細に記入すること) example 12. State the titles or subjects of books or papers (including graduation thesis) authored by the applicant with the name and address of publisher and the date of publication, if any. (著書、論文(卒業論文を含む)があればその題名、出版社名、出版年月日、出版場所を記入すること) 13. Proposed study program in Japan; state in more than 600 words, the details of your major field of study and study program. This item will be used as one of the most important references for selection. Statement must be typewritten in block letters. (日本での研究計画この研究計画は、選考の重要な参考となるので、専攻分野、研究計画を600字以上で詳細に記入すること。記入は、タイプ又は楷書によるものとする。） i) Field of study (専攻分野) ii) Study program in detail (研究計画：詳細に記入すること) 14. Your desired academic adviser (professor of Keio from whom you desire to have academic supervision) (指導を受けたい教授（希望指導教授）) Name（氏名）: I have contacted him/her. (希望指導教授に連絡を取ったことが) □ Yes (ある) □ No (ない) 15. Person to be notified in applicant’s home country, in case of emergency: (緊急の際の母国における連絡先) i) Name in full: (氏名) ii) Address with telephone number: (住所及び電話番号) iii) Occupation: (職業) iv) Relationship: (本人との関係) Please read the statement below, and sign your name. 次の文を読んで署名すること “I certify that the information given in this application is complete and accurate to the best of my knowledge, and, if admitted, I agree to comply with the rules and regulations of Keio University.” 「私は上記の事実に相違ないことを認め、入学後は慶應義塾大学の規則に従います。」 Date of application: (申請年月日) Applicant’s signature: (申請者署名) Applicant’s name in Roman block letters: (申請者氏名―ローマ字)