Short-Term Exchange Programs
at the University of Tsukuba, 2013-2014
Application Instruction
Contents
How to Apply ・・・・・・・・・・・・・・・・・・
1
Student Status and Tuition Fees・・・・・・・・・
3
Various Arrangements ・・・・・・・・・・・・・・
5
Inquiries
・・・・・・・・・・・・・・・・・・・・
6
Application Package Cover Sheet
and Checklist ・・・・・・・・・・・・・・・・・・
7
Application Forms for Exchange(Research)
Student at the University of Tsukuba・・・・・・・
8
Examples of formal letter for admission request:
Sample A and Sample B
・・・・・・・・・・・
12
“Annex”
・Application Form for Certificate of Eligibility
・Example for Completing Application Form for
Certificate of Eligibility
The University of Tsukuba
Application Guide for Short-Term Exchange Programs
How to Apply
Application procedures
1. Confirm that your home university has a student exchange agreement with the University of
Tsukuba.
2. Apply at the International Office or through the Exchange Coordinator in your home university
for the exchange program with the University of Tsukuba. There may be a preliminary screening
involved.
3. Applications are sent to the Exchange Coordinator at the University of Tsukuba. The Coordinator
evaluates the study plan and recommends candidates to an appropriate college or graduate
school participating in the student exchange agreement.
Application documentation
Please submit the following documentation together as a package, otherwise your application cannot
be considered.
Document
Application Form for Exchange (Research)
Student at the University of Tsukuba
(Form 2)
Formal letter of admission request by
President or an appropriate representative of
the applicant’s home university addressed to
President of the University of Tsukuba
Notes
See pp.9-12
This letter will be used for selection processes.
Please consult the International Office of your home
university to complete it. For format, please see
samples in this guide, Sample A (p.13) for exchange
students and Sample B (p.14) for exchange research
students.
Official transcript of academic records
Application for certificate of eligibility
Please see attachments of this guide.
A copy of your passport, if available.
(Copies should include ID page and pages
with Japanese immigration stamps, if any)
If you do not possess a valid passport, please submit
a memo regarding when and where you will apply
for a passport.
Three (3) photographs
(Two pieces of 30 x 40 mm,
a piece of 30 x 24 mm)
The photographs must be formal, hatless, without
background, and taken within three months. Please
write your name on the reverse side. All photographs must be identical.
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The University of Tsukuba
Application Guide for Short-Term Exchange Programs
Document
Notes
All applicants must submit this certificate. For a list
of estimated costs of attending the University of
Tsukuba, please see p.7. Your bank balance should
be more than the amount indicated in the list.
Certificate of bank balance and/or certificate
of financial assistance.
If you receive a scholarship, please include a
certificate of that financial assistance. In such a
case, the amount of your bank balance should be
more than the amount equal to the total amount of
your scholarship when subtracted from your
estimated costs in the list.
IMPORTANT NOTES:
All application materials should be sent directly from the Exchange Coordinator or the
International Program Office of your home university to the Exchange Coordinator of the
University of Tsukuba. Those without prior approval of the International Program
Office/Coordinator of a student’s home university will not be accepted.
All documents except your passport must be originals.
Documents to be submitted must be accompanied with Japanese or English translations if they are
written in other languages.
Submitted documents will not be returned.
Incomplete applications or those that have reached the University of Tsukuba after the appropriate
deadline date will not be accepted.
Academic calendar
The academic calendar of the University of Tsukuba is as follows:
Spring Semester : April 1 to September 30
Fall Semester : October 1 to March 31
Application schedule
There are two different deadline dates for applying to study at the University of Tsukuba, depending
on when you want to commence your study or research. Please see the table below.
Date commencing
studies
Deadline
for application
Announcement
of result
April 1, 2013
October 1, 2013
January 4, 2013
June 30, 2013
End-February, 2013
Mid-August, 2013
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Receiving
supporting
documents
Mid-March, 2013
Early-September, 2013
The University of Tsukuba
Application Guide for Short-Term Exchange Programs
Student Status and Tuition Fees
There are two types of status for students coming from our partner universities abroad: exchange
student (or tokubetsu chokogakusei) and exchange research student (or tokubetsu kenkyugakusei).
Since the difference between the two is critical, please read below carefully.
Exchange students (or tokubetsu chokogakusei)
Exchange students or tokubetsu chokogakusei are undergraduate students or graduate students of
another university who wish to attend courses at the University of Tsukuba. Their admission is
granted by mutual consultation between the two universities. Exchange students can earn credits if
they pass the required examinations, and credit transfer is also available, depending upon the system
at their home universities. Exchange students should confirm credit transfer arrangements with the
International Program Office at their home universities before applying for the exchange programs
at the University of Tsukuba.
Exchange research students (or tokubetsu kenkyugakusei)
Exchange research students or tokubetsu kenkyugakusei are graduate students of another university
who wish to conduct research under the guidance of an academic advisor (host professor) at the
University of Tsukuba. Their admission is granted by mutual consultation between the two
universities. Exchange research students will focus on research rather than attending courses, and
therefore they cannot earn credits. (It is possible, however, for them to audit some courses with the
prior approval of course lecturers.)
Tuition fees and tuition waiver
Both types of students must pay tuition fees to the University of Tsukuba. The amount for exchange
students is calculated on a per-credit basis and is currently set at 14,800 yen per credit. The tuition
fees for exchange research students are calculated on a per-month basis and are currently set at
29,700 yen per month.
NOTE: Since the tuition fees for exchange research students cannot be prorated on a daily basis, we
advise that you do not commence your research here in the middle of a semester.
Exchange students must pay his/her tuition fees at the beginning of each semester. Exchange
research students must do so for the entire exchange period at the beginning of their first semester.
Students who are admitted as either type of exchange student from institutions with which the
University of Tsukuba has a reciprocal tuition waiver agreement may be granted a tuition waiver.
Please be aware, however, that the existence of an exchange agreement does not necessarily mean
that you can be automatically granted a tuition waiver. (The number of students eligible for tuition
fee waiver is fixed according to each student exchange agreement. In cases where the number of
applicants exceeds the fixed number of tuition waiver places, the tuition fees will not be waived,
even if the University of Tsukuba has a reciprocal tuition waiver agreement with the home
university. For more information, please consult with the International Program Office of your
university.)
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The University of Tsukuba
Application Guide for Short-Term Exchange Programs
Summary: The following table compares the two types of student status, exchange students and
exchange research students.
Purpose of study abroad
Level
Admission
Earn credits
Transfer credits
Tuition Fees
Fee payment
Tuition waiver
When to start
Exchange students
Exchange research students
(tokubetsu chokogakusei)
(tokubetsu kenkyugakusei)
To attend classes and earn To conduct research under the
credits
guidance of Tsukuba’s supervisor
Undergraduate or graduate
Graduate
By mutual consultation between the University of Tsukuba and the
student’s home university
Possible to earn credits for Not possible to earn credits, but may
courses taken at the University audit courses with approval
of Tsukuba
Possible (confirm with your Not possible
university)
14,800 yen per credit
29,700 yen per month
Beginning of each semester
Beginning of first semester of
enrollment
Possible
Possible
Exchange research students can start
Exchange students can start to to enroll in the middle of the
enroll only at the beginning of semester, if they need to. But please
the semester. (Students who be aware that tuition fees and rent
plan to start in the second for residence cannot be paid on the
semester can do so either in prorated daily basis, but they must
August or September.)
be paid from the first day of the
month in which students first enroll.
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The University of Tsukuba
Application Guide for Short-Term Exchange Programs
Various Arrangements
Visa
Successful applicants must obtain a “College Student” visa to enter Japan as short-term exchange
students. To obtain the College Student visa, you need “Certificate of Eligibility for the Status of
Residence” issued by the Japanese Ministry of Justice.
We can process your visa application only after your acceptance to the University of Tsukuba is
confirmed and also all your documents, including financial documentation, are confirmed to be
complete. This makes your sending complete documentation to us essential for our handling of
application. Please note that any application with incomplete documentation cannot be reviewed.
For your reference to the schedule of application process, please see the “Application Schedule”
section of this guide, pp. 2.
Airport Transportation from Narita Airport or Haneda Airport
Express buses are available from Narita Airport or Haneda Airport to the central portion of Tsukuba
Science City, where the University of Tsukuba is located. It takes about two hours from Narita
Airport or Haneda Airport to Tsukuba Center Bus Terminal. If you arrive on the day the
International Student Center specifies, our staff members will meet you at Tsukuba Center and
accompany you to the university. If you prefer to take a taxi from the airports, discuss the payment
when you get into the cab.
Housing
The University of Tsukuba will make efforts to secure on-campus housing for successful applicants.
But married students who wish to be accompanied by their spouses are advised to find off-campus
housing, since rooms for married students are rather limited and the dates for applying for these
rooms do not correspond to the start dates for each semester at the University of Tsukuba.
Orientations
Upon arrival at Tsukuba, you are required to attend orientations regarding foreigner registration,
course registration procedures, student health insurances, Japanese language courses, life in
Tsukuba, and other useful matters.
Japanese language
Since most of the class instruction and research guidance are given in Japanese, a sufficient
knowledge of Japanese is essential to pursue your study or research in Japan. Therefore, you are
strongly recommended to study Japanese before coming to Japan.
Every semester the International Student Center offers 15 weeks courses of the Japanese language
for international students.
Academic advisor
A faculty member of an appropriate college will be appointed to each exchange student as his/her
academic advisor. These advisors will closely work with students and provide necessary information,
academic assistance, and other support.
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The University of Tsukuba
Application Guide for Short-Term Exchange Programs
Tutor
A student of the University of Tsukuba will be assigned as a tutor to each incoming international
student to assist in the study of the Japanese language, study in the international student’s major
field, and various kinds of procedures. Each tutor will provide about 45 hours of assistance per
semester.
Advisory services
Advisory services are available at the International Student Center. International students who are
confronted with problems in academic matters, human relations, or financial matters, etc. are
welcome to seek guidance from experienced advisors.
Japan’s national health insurance plan
All international students must enroll in Japan’s national health insurance plan, whose premiums are
about 20,000 yen for a year. This plan will cover seventy (70) percent of incurred medical costs.
Estimated costs of attending the University of Tsukuba
You must have a solid financial basis to live and study in a foreign country. The following table
provides the estimated average costs of studying and living in Tsukuba, including books and
supplies, tuition fees, health insurance, and other necessary expenses.
Duration of study
One (1) Semester
Two (2) Semesters
Without tuition waiver
868,000 yen
1,736,000 yen
With tuition waiver
600,000 yen
1,200,000 yen
Inquiries
General inquiries about our short-term exchange programs should be directed to the advisors
below through your exchange program office.
Prof. Nobutaka SUZUKI
Prof. Masako SHIBATA
International Student Center
University of Tsukuba
1-1-1 Tennodai, Tsukuba
Ibaraki 305-8577 JAPAN
Phone: +81-29-853-2776
Fax: +81-29-853-6204
Specific questions on courses offered by departments or programs should be directed to an
exchange coordinator at Tsukuba working for the agreement with your institution through
your exchange program office. All application materials also should be sent to the
exchange coordinator.
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Short-Term Exchange Programs
University of Tsukuba, 2013-2014
Application Package Cover Sheet and Checklist
Date (Month/Day/Year) 日付
Applicant’s Legal Name
出願者氏名
Home University, Country
出身大学、国名
IMPORTANT: Your application should be sent in a complete package containing the items below. After
checking all, your application package should be submitted to the International Program Office or the
Exchange Advisor at your home university. 以下の出願書類をすべて確認し、自分の大学の国際交流オフィスあるい
は学生交流アドバイザーに提出して下さい。
Documents to be submitted
Check
1. Application for Exchange (Research) Student at the University of Tsukuba (Form 2)
筑波大学短期留学生入学願書（別紙様式２）
2. Formal letter of request for admission by President or an appropriate representative of the
applicant’s home university addressed to President of the University of Tsukuba (see
attached Sample A or B) 本学学長宛の受入れ依頼書（Sample A もしくは B）
3. Official transcript of academic records 成績証明書
4. Application for Certificate of Eligibility
在留資格認定証明書交付申請書
5. A Copy of the page of your passport, if available
(Copies should include ID page and pages with Japanese immigration stamps, if any)
パスポートの身分事項、及び日本への入国歴がある場合にはそのスタンプがある頁のコピー
（すでに所有している場合）
6. Three
ID photos of different size
(two pieces (2) of 30 x 40 mm, a piece (1) of 30 x 24 mm
写真3枚（3 x 4 cm
2枚、3x2,4cm 1 枚）
7. Certificate to confirm the applicant’s bank account balance (if the applicant comes with
his/her own funds) 出願者の銀行口座残１高証明書（出願者本人が経費を支弁する場合）
8. Sponsor’s certificate of bank account balance, certificate of income, and certificate of
employment (if parents, relatives or friends sponsor your study with their funds) 経費支弁者
の銀行口座残高証明書､収入証明書及び在職証明書（両親や親族などが経費を支弁する場合）
9. Document to certify that the government scholarship or other scholarship agency of the
applicant’s home country supports his/her study. This document must include the amount of
the financial support while studying in Japan 奨学金受給証明書（出願者が自国の政府あるいは奨
学財団から奨学金を受給し､それによって経費を支弁する場合）
-7-
Form 2（別紙様式２）
筑 波 大 学 短 期 留 学 生 入 学 願 書
Application Form for Exchange (Research) Student at the University of Tsukuba
I herewith submit my application for admission to the University of Tsukuba as an Exchange (Research)
Student. 私は，短期留学生（特別聴講学生または特別研究学生）として貴学に入学を希望しますので，出願書
類等を提出いたします。
Please type or print clearly.
Applicant’s Legal Name
（in English alphabet）
出願者氏名（英語表記）
姓 Family Name
名 Given Name
Country of Citizenship
国 籍
Date of Birth
生年月日
Gender □ Male （男）
（性別） □ Female（女）
Marital Status
19
,
,
Yr. 年 Mon. 月 Day 日 未既婚の別
3cm × 4cm
□ Single
□ Married
(Please type or print clearly.)
Applicant’s Current
Address
出願者の現住所
Photo
（写真）
Middle Name
Phone:
Fax:
E-mail:
(Please type or print clearly.)
Address to which
application result is to
be sent
選考結果の送付先
Phone:
Exchange Coordinator’s
Name and Address
Name:
Address:
Fax:
E-mail:
(Please type or print clearly.)
交換留学コーディネー
タの氏名および連絡先
Phone:
Fax:
E-mail:
Name of Home
University (in English)
在籍大学名 (英語表記)
Address:
Name of Faculty / School
在籍学部 / 学科
Date of Admission
to Home University
在籍大学入学年月
Department / Major
学科／専攻
20
/
Yr. / Mon.
Expected Date of Graduation or Completion
在籍大学卒業あるいは修了予定年月
Current status 在籍年次
□ Undergraduate (□Sophomore □Junior □Senior)
□ Master Course (□1st □2nd □Other
year)
□ Doctoral Course (□1st □2nd □3rd □Other
/
Yr. 年
-8-
Mon. 月
year)
Language Proficiency 語学能力
Japanese Language
Background
日本語の学習歴
Japanese Language
Proficiency 日本語能力
(Evaluate your level and fill in
an X where appropriate.)
English Language
Proficiency 英語能力
(Evaluate your level and fill in
an X where appropriate.)
(2)
Name of Institution
Attended
学習機関の名称
(1)
Duration of Study
学習期間
Total:
Total:
Yr. 年
Mon. 月
Yr. 年
Mon. 月
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
Reading
Writing
Speaking
Reading
Writing
Speaking
Ⅰ．Your Study or Research Plan at the University of Tsukuba
筑波大学での学修計画
(1) Proposed study or research period at Tsukuba. Please indicate below the starting and ending
month of your stay and the total number of months. 希望する学修期間。希望の開始月と終月およ
び総月数を下に記入してください。
From
2013,
Yr. 年
,
Mon.月
1
Day 日
To
,
Yr. 年
Mon. 月
Total
, last day
Day 日
months 総月数
IMPORTANT: The above dates must be identical to those indicated in the formal letter of request
for admission addressed to President of the University of Tsukuba (see Sample A or B). The following table shows our academic calendar for your reference.
注：上の期日は、筑波大学学長宛の受入れ依頼書（様式Sample A or B）に記載される期間と同じもので
なければなりません。筑波大学の学年歴は以下の通りです。
Spring Semester 春学期
Fall Semester 秋学期
April 1 to September 30
４月１日～９月３０日
October 1 to March 31 １０月１日～ ３月３１日
(2) Describe your academic field at your home university 出身大学での専攻分野
(3) Proposed field of study or research at Tsukuba
筑波大学で希望する学習･研究分野
(4) Courses you plan to enroll in at Tsukuba or your research topic 希望聴講科目あるいは研究テーマ
-9-
(5) Explain in detail your study plan or research plan at Tsukuba. (You can use an extra sheet of
paper, if necessary. 筑波大学での詳細な学習･研究計画 (ｽﾍﾟｰｽが足りない場合には、別紙に記入して下さい。)
- 10 -
Ⅲ. Student Status at Tsukuba
学生身分
This portion is only for applicants at the graduate level, who must read and answer the below carefully.
大学院レベルの学生は、以下をよく読み記入してください。
There are two types of student status for graduate students from our oversea partners: exchange student
and exchange research student. Exchange students are required to register for courses and earn credits
at Tsukuba, whereas exchange research students will receive guidance and advices for research from
Tsukuba’s faculty members, but they cannot earn credits. You must choose your status one or the other.
大学院レベルの特別聴講学生は科目登録し、単位を取得しなければなりません。特別研究学生について
は、本学で研究指導を受けることを目的としており、単位を取得することはできません。
Please indicate below the student status you choose.
筑波大学において、自分が希望する身分を選択してください。
□ Exchange Student (tokubetsu chokogakusei)
特別聴講学生
□ Exchange Research Student (tokubetsu kenkyugakusei) 特別研究学生
NOTE: Since you cannot change your student status after you are admitted, you must choose your status
carefully. Also the student status you have chosen must be indicated in the formal letter of admission request
from your institution addressed to President of the University of Tsukuba (see Sample A or B of this guide.)
入学後の身分変更はできませんので、慎重に自分の身分を選択してください。選択した身分は、本学学
長宛の受入れ依頼書に記載されている身分と同じものでなければなりません(本ガイドのSample Aあるい
はBを参考)。
Applicant Signature:
出願者署名
Date:
日付
Month / Day / Year
Home University Endorsement (To be completed by the applicant’s exchange advisor)
出身大学における確認（以下は、出願者の学生交流アドバイザーによって確認され、署名されなければな
りません。）
I have verified that the applicant is submitting a complete package containing the items listed on p.8.
After reviewing them, I recommend the applicant’s participation in the exchange program.
私は、出願者が8頁に記されている必要書類のすべてを提出していることを確認しました。それを検討した後、
私はこの出願者が当該の学生交流プログラムに参加することを推薦します。
Printed Name:
氏名
Title of Position:
職名
Signature:
署名
Date:
日付
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Month / Day / Year
Sample A: For Exchange Students
The following is a sample letter for admission request for exchange students (tokubetsu chokogakusei). Please make sure
to include in the letter the seven (7) conditions indicated below.
Date: Month Date, Year
(Example: November 1, year)
Dr. Nobuhiro Yamada
President
University of Tsukuba
Tsukuba, Ibaraki, 305-8577 Japan
Student’s school year,
department, faculty, and
Student’s name
university
Dear Dr. Nobuhiro Yamada:
It is my pleasure to recommend to you our undergraduate/graduate student, Mr. Michael Smith, a third-year student in the
Department of XXXXX, Faculty of XXXXX, University of XXXXX. (school year, department, faculty, university).
Recommendation
He is an excellent student who is very interested in the Japanese language, society, and culture. In pursuing his research theme,
we believe that he would greatly benefit from a short-term exchange program in Japan.
Beginning period of
He would like to study as an exchange student at your university from April 201X.
study
We understand that the following conditions apply for his acceptance as an exchange student at your university:
His student status at the University of Tsukuba shall be exchange student (tokubetsu chokogakusei);
His period of study at the University of Tsukuba shall be from [DATE] to [DATE];
Same status and dates as described
His field of study at the University of Tsukuba shall be [FIELD];
in the Application (Form 2)
The course work done by the above student at the University of Tsukuba shall be evaluated using the University of
Tsukuba grading system;
A certificate concerning the above student's grades at the University of Tsukuba shall be issued after the completion of his
study;
Credits received from the University of Tsukuba are fully applicable to the graduation requirements at the University of
XXXXXX; and
The above student shall be allowed to use all facilities necessary for his study at the University of Tsukuba.
I’d appreciate it if you would consider admitting him to your university under the conditions listed above.
Sincerely,
(signature)
XXXXX XXXXX
President
University of XXXXXX
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Sample B: For Exchange Research Students
The following is a sample letter for admission request for exchange research students (tokubetsu kenkyugakusei).
Please make sure to include in the letter the six (6) conditions indicated below.
Date: Month Date, Year
(Example: November 1, year)
Dr. Nobuhiro Yamada
President
University of Tsukuba
Tsukuba, Ibaraki, 305-8577 Japan
Student’s school year,
department, faculty, and
Student’s name
university
Dear Dr. Nobuhiro Yamada:
It is my pleasure to recommend to you our graduate student, Ms. Jane Smith, a second-year student in the Department of
XXXXX, Faculty of XXXXX, University of XXXXX.
Recommendation
She is an excellent student who is very interested in the biological processes of marine life. In pursuing her research theme, we
believe that she would greatly benefit from a short-term study exchange period in Japan.
She would like to study as an exchange research student at your University from April 201X.
Beginning period of study
We understand that the following conditions apply for her acceptance as an exchange research student at your university:
Same status and dates as described in
the Application (Form 2)
Her student status at the University of Tsukuba shall be exchange research student (tokubetsu kenkyugakusei);
Her period of study at the University of Tsukuba shall be from [DATE] to [DATE];
Her research theme at the University of Tsukuba shall be [BRIEF DESCRIPTION of RESEARCH];
The research work done by the above student at the University of Tsukuba shall be evaluated using the University of
Tsukuba grading system;
An official letter concerning the above student's research work done at the University of Tsukuba shall be issued after the
completion of her study; and
We request that the above student shall be allowed to use all facilities that are necessary for her research at the University
of Tsukuba.
I’d appreciate it if you would consider admitting her to your university under the conditions listed above.
Sincerely,
(signature)
XXXXX XXXXX
President
University of XXXXXX
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別記第六号の三様式（第六条の二関係）
申請人等作成用 １
日本国政府法務省
Ministry of Justice, Government of Japan
For applicant, part 1
在 留 資 格 認 定 証 明 書 交 付 申 請 書
APPLICATION FOR CERTIFICATE OF ELIGIBILITY
TOKYO 入国管理局長 殿 To the Director General of
写 真
Regional Immigration Bureau
Photo
出入国管理及び難民認定法第７条の２の規定に基づき，次のとおり同法第７条第１項第２号に掲げ
る条件に適合している旨の証明書の交付を申請します。
Pursuant to the provisions of Article 7-2 of the Immigration Control and Refugee Recognition Act, I hereby apply for the certificate showing
eligibility for the conditions provided for in 7, Paragraph 1, Item 2 of the said Act.
40mm×30mm
2 生年月日
1 国 籍・地 域
Nationality/Region
Family name
年
Date of birth
Given name
月
Year
日
Month
Day
3 氏 名
Name
4 性 別
Sex
男 ・ 女
5 出生地
Male/Female
6 配偶者の有無 有
Place of birth
7 職 業
・
無
Married / Single
Marital status
8 本国における居住地
Occupation
Home town/city
9 日本における連絡先 茨城県つくば市天王台1-1-1 筑波大学留学生交流課
Address in Japan
電話番号
10 旅券
Passport
携帯電話番号
029-853-6089
Telephone No.
Cellular phone No.
(1)番 号
(2)有効期限
Number
Date of expiration
年
月
日
Year
Month
Day
Purpose of entry: check one of the followings
11 入国目的 （次のいずれか該当するものを選んでください。）
□ Ｉ 「教授」
□ Ｉ 「教育」
□ Ｊ 「芸術」
□ Ｊ「文化活動」
□ Ｋ 「宗教」
"Professor"
"Instructor"
□ Ｌ 「企業内転勤」
"Artist"
"Cultural Activities"
□ Ｍ 「投資・経営」
□ Ｌ 「研究（転勤）」
"Intra-company Transferee"
"Investor / Business Manager"
□ Ｎ 「人文知識・国際業務」
□ Ｑ 「研修」
"Trainee"
"Technical Intern Training(i)"
□ Ｔ 「日本人の配偶者等」
Date of entry
"Designated Activities (c)"
"Spouse or Child of Permanent Resident"
年
月
Year
日
Month
Day
14 滞在予定期間
"Entertainer"
□ Ｒ「特定活動(ハ)」
□ Ｔ「永住者の配偶者等」
"Spouse or Child of Japanese National"
12 入国予定年月日
"Dependent"
■ Ｐ 「留学」
"Student"
□ Ｒ「特定活動（EPA家族）」
□ Ｔ「定住者」
"Long-Term Resident"
"Dependent of EPA"
□ Ｕ 「その他」
Others
13 上陸予定港
Port of entry
15 同伴者の有無
Intended length of stay
"Engineer"
□ Ｏ 「興行」
"Designated Activities (a/b)"
□ Y 「技能実習（１号）」 □ Ｒ 「家族滞在」
□ Ｎ 「技術」
"Researcher"
□ Ｎ 「特定活動（イ・ロ）」
"Skilled Labor"
"Journalist"
□ Ｎ 「研究」
"Researcher (Transferee)"
□ Ｎ 「技能」
"Specialist in Humanities / International Services"
□ Ｌ「報道」
"Religious Activities"
Accompanying persons, if any
有 ・ 無
Yes / No
16 査証申請予定地
Intended place to apply for visa
17 過去の出入国歴
有 ・ 無
Past entry into / departure from Japan
Yes / No
（上記で『有』を選択した場合） (Fill in the followings when the answer is "Yes")
回数
回
time(s)
年
直近の出入国歴
The latest entry
from
Year
月
Month
日 から
Day
to
月
年
Month
Year
日
Day
18 犯罪を理由とする処分を受けたことの有無 （日本国外におけるものを含む。） Criminal record (in Japan / overseas)
有 （具体的内容
）・無
Yes (Details
) / No
19 退去強制又は出国命令による出国の有無
Departure by deportation /departure order
（上記で『有』を選択した場合）
(Fill in the followings when the answer is "Yes")
有 ・ 無
Yes / No
回数
回
time(s)
直近の送還歴
月
年
The latest departure by deportation
Month
Year
日
Day
20 在日親族（父・母・配偶者・子・兄弟姉妹など）及び同居者
Family in Japan (Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents
続 柄
氏 名
Relationship
Name
生年月日 国 籍・地 域 同居予定
Date of birth
Nationality/Region
Intended to reside
with applicant or not
はい・いいえ
Yes / No
はい・いいえ
Yes / No
はい・いいえ
Yes / No
はい・いいえ
Yes / No
勤務先・通学先
在留カード番号
特別永住者証明書番号
Place of employment/school
Special Permanent Resident Certificate number
Residence card number
（注） 裏面参照の上，申請に必要な書類を作成して下さい。Note : Please fill in forms required for application. (See notes on reverse side.)
申請人等作成用 ２ Ｐ （「留学」）
For applicant, part 2 P ("Student")
在留資格認定証明書用
For certificate of eligibility
21 通学先 Place of study
(1)名 称
筑波大学
Name of school
(2)所在地
Address
(3)電話番号
茨城県つくば市天王台1-1-1
Telephone No.
029-853-6089
22 修学年数 （小学校～最終学歴）
年
Total period of education (from elementary school to last institution of education)
Years
23 最終学歴 （又は在学中の学校） Education (last school or institution) or present school
(1)在籍状況
□ 卒業
■ 在学中
□ 休学中
□ 中退
Registered enrollment
Graduated
In school
Temporary absence
□ 大学院 （博士）
□ 大学院 （修士）
□ 大学
□ 高等学校
□ 中学校
□ その他 （
Doctor
Senior high school
Master
(2)学校名
□ 短期大学
Bachelor
Junior high school
Withdrawal
□ 専門学校
Junior college
College of technology
）
Others
(3)卒業又は卒業見込み年月日
Name of the school
Date of graduation or expected graduation
月
年
日
Month
Year
Day
24 日本語能力 （専修学校又は各種学校において日本語教育以外の教育を受ける場合に記入）
Japanese language ability (Fill in the followings when the applicant plans to study at advanced vocational school or vocational school (except Japanese language))
□ 試験による証明Proof based on a Japanese language test
（１）試験名 Name of the test
（２）級又は点数
Attained level or score
□ 日本語教育を受けた教育機関及び期間 Organization and period to have received Japanese language education
機関名
Organization
期間：
Period from
年
月
Year
から
Month
年
to
月 まで
Year
Month
□ その他
Others
25 日本語学習歴 （高等学校において教育を受ける場合に記入）
Japanese education history (Fill in the followings when the applicant plans to study in high school)
日本語の教育又は日本語による教育を受けた教育機関及び期間
Organization and period to have received Japanese language education / received education by Japanese language
機関名
Organization
期間：
Period from
年
月
Year
から
Month
年
to
月 まで
Year
Month
26 滞在費の支弁方法等 Method of support to meet the expenses while in Japan
(1)支弁方法及び月平均支弁額 Method of support and an amount of support per month (average)
□ 本人負担
円
□ 外国からの送金
Self
Yen
□ 外国からの携行
Remittance from abroad
円
Carrying from abroad
Yen
（携行者
携行時期
Who
）
When
□ 在日経費支弁者負担
円
Supporter in Japan
Yen
□ その他
円
Others
Yen
□ 奨学金
Scholarship
(2)経費支弁者 Supporter
①氏 名
Name
②住 所
電話番号
Address
Telephone No.
③職業 （勤務先の名称）
電話番号
Occupation (place of employment)
④年 収
Annual income
円
Yen
Telephone No.
円
Yen
円
Yen
申請人等作成用 ３ Ｐ （「留学」）
For applicant, part 3 P ("Student")
在留資格認定証明書用
For certificate of eligibility
(3)申請人との関係 （上記(1)で外国からの送金，外国からの携行又は在日経費支弁者負担を選択した場合に記入）
Relationship with the applicant (Check one of the followings when your answer to the question 26(1) is remittance from abroad,
carrying from abroad or supporter in Japan)
□夫
□妻
Husband
□父
Wife
□ 兄弟姉妹
□母
Father
□ 祖父
Mother
□ 祖母
Grandfather
□ 叔父 （伯父）・叔母（伯母）
Brother / Sister
Uncle / Aunt
□ 友人・知人の親族
□ 養父
Grandmother
Foster father
□ 受入教育機関
□ 養母
Foster mother
□ 友人・知人
Educational institution
Friend / Acquaintance
□ 取引関係者・現地企業等職員
Relative of friend / acquaintance
Business connection / Personnel of local enterprise
□ 取引関係者・現地企業等職員の親族
□ その他 （
Relative of business connection / personnel of local enterprise
）
Others
(4)奨学金支給機関 （上記(1)で奨学金を選択した場合に記入）
Organization which provide scholarship (Check one of the following when the answer to the question 26(1) is scholarship)
□ 外国政府
□ 日本国政府
Foreign government
□ 地方自治体
Japanese government
Local government
□ 公益社団法人又は公益財団法人
）
□ その他 （
Public interest incorporated association or public interest incorporated foundation
27 卒業後の予定 Plans after graduation
■ 帰 国
□ 日本での進学
Return to home country
□
）
Others
Enter school of higher education in Japan
□ その他 （
日本での就職
）
Others
Find work in Japan
28 申請人，法定代理人，法第７条の２第２項に規定する代理人
Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.
(1)氏 名
(2)本人との関係
Relationship with the applicant
Name
(3)住 所
Address
茨城県つくば市春日1-8-3 筑波大学春日プラザ
電話番号
Telephone No.
携帯電話番号
029-853-8029
Cellular Phone No.
以上の記載内容は事実と相違ありません。
申請人（代理人）の署名／申請書作成年月日
注 意
受入機関の職員
I hereby declare that the statement given above is true and correct.
Signature of the applicant (representative) / Date of filling in this form
年
月
日
Year
Month
Day
申請書作成後申請までに記載内容に変更が生じた場合，申請人（代理人）が変更箇所を訂正し，
署名すること。
Attention In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant
(representative) must correct the part concerned and sign their name.
※ 取次者
Agent or other authorized person
(1)氏 名
Name
(3)所属機関等
(2)住 所
Address
Organization to which the agent belongs
電話番号
Telephone No.
記入例 <Sample>
Read the description carefully and fill in all the necessary
information.
●写真（縦4cmx横3cm、無背景、裏に名前と国籍を記入）は、貼り付けずに、申
請書と一緒に提出して下さい。
Please submit your photograph (4 cm×3 cm, clear background, and with your name and nationality
on the back of the photograph) with your application. Do not attach it to the application.
●パスポートに記載されているとおりのアルファベット表記名を記入すること。
Write your name in alphabet as written in your passport.
●出生地には都市名まで記入すること。本国における居住地は詳細に記載して下
さい。 （○○省○○市＜県＞～○号）また、中国人は漢字で記入すること。
Write the name of the city and country in the “Place of birth”. About “Home town/city”, please
write the complete address. And for Chinese students, write in Kanji.
●パスポート番号と有効期限を記載してください（パスポート申請中の場合は
「申請中」と書いてください）。Write the passport number and date of expiration. If you
have applied for one and you are presently waiting for its issuance, just write "Application submitted"
●入国予定年月日は、申請書作成の時点における予定年月日を記載してください。
In the field of “Date of entry”, write the expected date of entry at the time of your application.
●滞在予定期間は、筑波大学での在籍期間を書いてください。
For the "period of stay", please write the study or research period at the University of
Tsukuba.
●審査予定地を必ず記入して下さい。
Please be sure to write the place where you are planning to apply for a visa.
●出入国歴は、過去の日本への出入国の回数と直近（最近）の出入国期間を正確
に記載してください。記載内容に虚偽があると、在留資格認定証明書は交付され
ません。また、今後日本への入国を認められないことがあります。
In the field of “Past Entry into/departure from Japan”, write the number of entries into Japan in the
past, if any, and the latest period of stay. If you fail to report the accurate record of entry, the
certificate of eligibility will never be issued. In the worst case scenario, you will not be able to enter
Japan for years to come.
●日本に親族または同居者がいる場合には名前、その他の情報を記載して下さい。
いない場合は「ＮＯＮＥ」と記載してください。
If you have a family or co-residents in Japan, write their names and other information. If you don‘t
have any family in Japan, just write “NONE” in the field of “Family in Japan or co-residents”.
●小学校から本国の在籍教育機関を卒業するまでの修学年数を書いて下さ
い。
Write the total period of education from elementary school to the current education institute
where you will graduate in your country.
●あなたの最終学歴の在籍状況と課程にあてはまるものにチェックし、学
校名と卒業（予定）年月日を記入してください。
Check the field that matches your last student status and institution. Write the name of the
institution and the date of the graduation.
●日本語能力を証明する試験を受けた者は、試験名と、取得級または点数を書いてく
ださい。また、その証明書の写しを一緒に送ってください。
For those who took an examination that certifies their Japanese language ability, write the
name of the examination and the acquired class or score. In addition, send a copy of the
certificate.
●本学に入学する前に日本国内の学校（日本語学校を含む）に在籍した者は、その
出席証明書及び成績証明書を一緒に送ってください（交換留学による在籍を含む）。
Please attach the certificate of Attendance and academic record (including students admitted
in exchange programs) if you stayed in school in Japan (Japanese language school, etc.) before
enrolling in our university.
●滞在費（生活費・学費）の送金方法にあてはまるものにチェックしてく
ださい。また、その月額（平均）を記載してください。
Check how the supporter will send money for your cost of living and tuition fee in Japan, and
also write the (average) amount of support per month.
※送金額は、同封する経費支弁書の生活費月額、または生活費月額と学
費の月平均額を足した金額と一致していること。
The amount of the remittance must be equivalent to the amount of the monthly living
expenses or the total amount of the monthly living expenses and the monthly average of the
tuition stated in the enclosed Written Oath for Defraying Expenses.
●奨学金を受給する場合は、チェックしてください。また、その月額を記
載してください。For scholarship recipients, check the field and also write the amount of
the scholarship per month.
●経費を支払う人の氏名、住所、職業、電話番号及び年収を記載してくだ
さい。
Write your supporter's name, address, occupation, telephone number and annual income.
※経費支弁者の年収額は同封する収入証明書の金額と一致していること。
（証明できない収入は年収として認めない。）
The amount of the supporter’s annual income must be equivalent to the amount certified by the
enclosed Certificate of Income. (We do not consider income that cannot be certified as annual
income.)
●申請人と経費を支払う人との関係をチェックしてください。
Check the relationship between you and your supporter.
●奨学金を受給する場合は、奨学金名を記入してください。
For scholarship recipients, write the name of the scholarship.
●入学を認められたコースを修了した後の予定についてチェックしてくだ
さい。
Check the field that matches what you plan to do after completion of the course you have
been admitted.
●大学に代理申請を依頼する人は記入しないこと。（大学側で記入しま
す。）
If you request our university to apply for the certificate by proxy, DO NOT WRITE HERE.
(We will fill in these fields.)
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