SAMPLE 博士平成23年度筑波大学大学院○○○○課程入学願書次の事項に記入又は番号等に○を付けてください（入学願書等記入上の注意参照）。 ※欄は記入しないでください。出願方法① b 出願時の身分 e 一般１学生１２社会人有職者 (非常勤除く) ２ツクバフリガナ研究生・その他出願時の留学生等区分 f ３タロウ男女筑波太郎受験番号研究所１コード１私費 ※ a １２１物・材コース２ 2学期入学（8月入学） d ４本籍茨城 g 本籍コード (外国人：国名) ４ 0 8 h 改姓年月及び旧姓 l k 昭平成年月日年齢和２３６１０７１５２３歳 Applicant's Category: Circle your application category （1(一般): General, 2(社会人): Working Adults） c Application Type: "連携" = Cooperative Graduate School Cirle "1" if applicable. (Refer to the Application Guide or the following webpage) http://www.tsukuba.ac.jp/english/organization/cooperative.html c "物・材コース"= Cirle "4" if you apply for the course in the Master's Program in the Graduate School of Pure and Applied Sciences which corresponds to the "3-year Doctoral Program in Materials Science and Engineering" in the Graduate School based on affiliation with National Institute for Materials Science(NIMS) . d Second Trimester (August) Admission: Circle "2" if applying for the second trimester (August) admission to the Graduate School of Pure and Applied Sciences e Status as of Application: 1:Regular Student, 2:Working People, 3: Others f Monbukagakusho Scholarship Status: 1: Monbukagakusho Scholarship Student, 2: Financed Student Privately g Country of Citizenship h Name in Japanese Katakana j Sex: 1: Male, 2: Female k Date of Birth/Age: Year in Japanese Era, Month and Day （旧姓：　） l Date of Change of Family Name/Previous Family Nama: Fill in if applicable. Attach a document to certify the change of your family name if you changed your family name due to marriage, etc. m Applicant's Address, Telephone Number and Cell-phone Number: For address, be sure to write the block number, house number, appartment name and room number. Do not omit these. Also fill in your telephone number properly. n Contact Person's Name, Relationship, Address & Telephone Number: Fill in contact information of the applicant's father, mother, uncle, friend or somebody who knows the applicant very well and can be contacted. Fill in their name, address and telephone numbe properly. o Graduate School Name & Code: Refer carefully to the samples in "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide before filling in. p Program Name & Code: Refer carefully to the samples in "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide before filling in. q Course Name: Refer carefully to the samples in "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide before filling in. r Research Field: Refer carefully to the samples in "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide before filling in. s Prospective Academic Advisor's Name: Refer carefully to the samples in "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide before filling in. t Examination Subject: Refer carefully to the samples in "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide before filling in. u Request for Special Assistance: If you have any physical disability and need any assistance on the examination date, go through the prescribed procedure by the due date before application. Circle "要" if assistance is required. v Pre-application Screening: Refer to "出願資格(Eligibility)" and "入学願書等の記入上の注意 (Notes for Filling in Appliation Forms)" in the application guide and if applicable, go through the prescribed procedure for the pre-application screening by the due date before application and circle "要". 〔電話 ○○○（ ○○○ ）○○○○　〕　〔携帯電話　○○○（ ○○○○　）　○○○○　〕 m 本人以外氏名の連絡先 (ﾌﾘｶﾞﾅ） (日本国内) n 住所 ○　○　○　○　（　○ ○ ○ ○　○ ○ ○　）〒３０５－００３５茨城県土浦市下高津○丁目○番地○号 ○○○○○○研究科志望研究領域名 ○ ○ ○○○ 専攻 ○○○ r 受験科目t 本人との関　係父 q ○ 希望指導教員名 s 受験特別措置 ○○　○○○ 出願資格審査 u 口　述　試　験国　立公　立１２私　立３外　国４その他５国　立１公　立２私　立３外　国４その他大　学　名５ ○○大学学群・学部名 ○○○学部学類・学科名 ○○○学科大学名（大学院）研究科名専攻名 v 要不要要不要 ※ a 卒業見込み卒業その他 a 修了見込み修了昭和平成年月２３２１０３１２５ ※ 卒業（見込）年月その他３４５修了（見込）年月昭和平年月成２３ w （備考）外国人留学生は、入学手続き時までに必ず「留学」の在留資格を得てください。 i Name in Kanji (Chinese Character)/Roman Alphabet 〔電話 ○○○（ ○○○ ）○○○○　〕志　望　コ　ー　ス志望研究科名及び研究科ｺｰﾄﾞ志望専攻名及び専攻ｺｰﾄﾞ p o w b 年　月改姓〒 ○○○－○○○○ 現住所 ○○県○○○市○○５丁目３番　○○アパートB３０５室出願資格 Do NOT Fill in a 生　年　月　日 j i 国費性別 h 氏　名連携出願方法② c ※ a 出願資格適用条項 ※ a ＜　添　付　欄　＞ w ○「検定料受付証明書」又は「検定料収納証明書」を、この枠内にはがれないようにのり付けしてください。注：検定料受付証明書（郵便局・指定銀行用）は、「受付局日附印」がない場合は受理できません。検定料収納証明書（コンビニエンスストア用）は、「収納印」不要です。 x x Eligibility (Type of University (foreign university is 4), Name of University, Department & School which the Applicant Graduated/Will Graduate from, Graduation Staus, Graduatation Date(in Japanese Era)): [For master's program applicants] Fill in the name of the university you graduated from and the (expected) graduation date in the upper column. If you have graduated from (or currently enroll in) a graduate school , fill this information in "履歴書 (Resume)" on the backside. Do NOT include it here. [For continuing 3-year doctoral program or 3-year doctoral program applicants] Fill in the name of the university and graduate school completed and the (expected) completion date in the lower column based on the application. Do not fill in the upper column. Space for Pasting Certificate of Payment of Examination Fee: Paste "検定料受付証明書" or "検定料収納証明書" (Certificate of Payment of Application Fee) within the given frame. Monbukagakusho scholarship students, master's program students who complete their course in March 2011 and intend on applying for the continuing 3-year doctoral program are not required to pay the application fee.