Application Documents

Application Documents
【Autumn Admission, 2015】
KIU Preliminary Survey Form(A)
(1st Screening)
□
Undergraduate
□
Transfer
□
International College Program
( )
Department of
Department of
( )
Economics and Management
Urban Environment & Tourism
※Circle (〇) the 1st choice in case you apply for both Undergraduate and Transfer.
※Tick ☑ all the boxes you want to apply for. (Multiple answers allowed.)
１．
Name
Last:
２．
Date of Birth
Year: １９
３．
Place of Birth
State/Prefecture:
First:
Month:
Middle:
( Male ・ Female )
Day:
Married
( Yes / No )
City:
Addr e s s i n Hom e Co u n tr y
４．
Cell Phone Number
５．
Educational Background
Name of School
Date of Entry
Date of Graduation
Period of Study
High School
Y
M
Y
M
years
University
Y
M
Y
M
years
Others
Y
M
Y
M
years
６．
Work History
Name of Company
７．
Address
Job Category
Y
M
～ Y
M
Y
M
～ Y
M
Japanese Educational History
Name of School
Address
Period of Study
Y
JLPT: Level (
８．
Period of Employment
) （Pass・Fail・Under Applications）
J.TEST: Level (
９．
Have you ever applied for permission to stay in Japan?
M
～ Y
Study Hours
M
hours
) （Pass・Fail・Under Application）
Plans after Graduation
Do you have relatives or acquaintances in Japan?
（ YES ・ NO ）
10.
（ YES ・ NO ）
11．Agent and Contact Information
Financial supporters
Name
relationship
Occupation
Name of Agent
Contact Person
Phone Number
Photo Attached Here
Applicant’s Signature
Date
2015
/
/
【Autumn Admission, 2015】 1/2
Application Form（B）
□
Undergraduate
□
Transfer
□
International College Program
Department of
( )
( )
Economics and Management
Department of
Urban Environment & Tourism
※Circle (〇) the 1st choice in case you apply for both Undergraduate and Transfer.
※Tick ☑ all the boxes you want to apply for. (Multiple answers allowed.)
【Applicant】
Last
First
（in Katakana）
Photo
Name
（in English）
Male
Female
・
Year
Date of Birth
Single
Month
Day
（Age
Nationality
Place of Birth
Last School
Occupation
４ｃｍ×３ｃｍ
Married
・
）
※Attached here
Current Address （Home）
Contact Information
Phone （Home）
(in full)
Fax（Home）
Cell Phone
Have you ever applied for permission to stay in Japan?
（ YES ・ NO ）
* If YES, provide the following information.
Immigration Office you have applied for a visa
Reason for Rejection
Passport
（ YES
・
NO ）
* If YES, provide the following information.
Passport No.
Date of Issue
Year
Month
Day
Date of Expiration
Year
【Financial Supporter】
Last
Name
First
（in Katakana）
（in English）
Date of Birth
Year
Month
Day
Name of Company
Title
Income of last year (before tax deduction)
Contact
Information
Address of Company
Phone (Company)
Fax (Company)
Current Address (Home)
Phone (Home)
Cell Phone
Fax (Home)
Month
Day
3．Applicant’s family (relative within the 2nd degree of relation and family member not living together are also to be included） 2/2
History of
Name
Relationship
Date of Birth
application for
Living
permission to
together
Occupation
stay in Japan
yy
mm
dd
Yes No
Yes No
yy
mm
dd
Yes No
Yes No
yy
mm
dd
Yes No
Yes No
yy
mm
dd
Yes No
Yes No
yy
mm
dd
Yes No
Yes No
yy
mm
dd
Yes No
Yes No
4．Educational Background
Name of School
Address
Date of Entry
Date of Graduation
Period of Study
Elementary School
City
Y
M
Y
M
years
Junior High School
City
Y
M
Y
M
years
High School
City
Y
M
Y
M
years
University
City
Y
M
Y
M
years
Others
City
Y
M
Y
M
years
5．Work History
Name of Company
Address
Job Category
Period of Employment
City
Y
City
Y
M
～ Y
M
M
～ Y
M
6．Japanese Educational History
Name of School
Address
Period of Study
Study Hours
City
Y
M
～ Y
M
hours
City
Y
M
～ Y
M
hours
7．Relatives in Japan (parent, child, brother, sister, etc) and persons living together
workplace ・
Date of
Name
relationship
Nationality
birth
8．
Residence card
address
school name
number
Plan after Graduation
I hereby declare the above statement is true and correct. I agree that my admission will be canceled if there is false information in this application.
Applicant’s Signature
Date
2015
/
/
【Autumn Admission, 2015】
Reasons for Application(C)
1. Reasons for Application
2. Plans after Graduation from Kokusai Bekka (Only for Applicants for International College Program)
Kobe International University ・
Others（
）
Applicant’s Signature
Date
2015
/
/
【Autumn Admission, 2015】
Statement of Financial Support(D)
To Kobe International University
Name
Nationality
Date of Birth
/
Year
/
Month
( Male ・Female )
Day
I agree to defray all costs for the above person during his/her stay in Japan, and therefore I
will explain the circumstances of this agreement below.
1.
Reason for defraying the applicant’s expenses
(Please explain in detail the circumstances where you have agreed to defray the applicant’s costs and your relationship to
him/her.)
2.
Particulars of Agreement
I,
, hereby agree to defray the costs of the above person during his/her
stay in Japan. In order to prove that I have defrayed his/her living expenses, I also agree to
provide documents, such as copies of evidence of telegraphic transfer or of his/her bank
account book that indicates remittance record when he/she applies for an extension of stay.
(1) Tuition
Annually
yen
(2) Living Expenses
Monthly
yen
(3) Method of Payment (Please explain in detail, e.g. bank transfer, money order, etc.)
Financial Supporter:
Name
(Last)
(First)
(Middle)
Address
Phone
Signature
Relationship to Applicant
(Date)
2015
Year
/
/
Month
Day
Health Declaration
【Autumn Admission, 2015】
全て記入すること（to be filled out）
志願者氏名
Name
現住所
Address
(Signature）
□男　Male
□女　Female
生年月日
Date of birth
国籍
Nationality
１．　身長（Height）　cm
体重（Weight）
kg
２．既往歴について、ある場合はチェックし、年齢を記入してください。
History of past illness : （if any,indicate it with your age of contraction.）
結核
□　Tuberculosis
歳(Age）
マラリア
Malaria
□
歳(Age）
リウマチ □
Rheumatic fever
歳(Age）
てんかん □
Epilepsy
歳(Age）
腎疾患 □
Kidney diseases
歳(Age）
心臓疾患 □
Cardiac diseases
歳(Age）
糖尿病 □
Diabetes
歳(Age）
アレルギー □
歳(Age）
Allergy
□
Other communicable diseases
その他の伝染病疾患　歳(Age）
３．現在、治療中の病気がある場合はチェックしてください。
Present Condition : (if any, please indicate)
扁桃腺、鼻または咽喉 -－－□
Tonsils, Nose or Throat
心臓または血管
-－－□
Heart or Blood Vessels
胃または消化器官 -－－□
Stomach or Digestive System
泌尿生殖器
Genito - Urinary
脳または神経組織 -－－□
Brain or Nerbous System
血液または内分泌器官 -－－□
肺または呼吸器官 -－－□
Lungs or Respiratory System
骨、関節または運動器官
その他内臓器官
-－－□
Other Abdominal Organs
皮膚
Skin
-－－□
Blood or Endocrine System
-－－□
Bones, Joints or Locomotor
-－－□
４．現在の健康状態は次のとおりである。
My health and physical coniditions are :
優　---□
Excellent
良　---□
Good
可　---□
Fair
不可　---□
Poor
５．その他特記事項があれば記入してください。
Any other remarks :
Please read "Submission of Documentary Proof of Immunization" on page 9 carefully.

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