Application Form

Application Form
Autumn 2015
Osaka University Chemistry-Biology Combined Major Program
Osaka University
大阪大学　化学・生物学複合メジャーコース2015秋　応募願書
Ⅰ Personal Details
Family　Name/Surname
Middle Name
First Name
Attach
ID Photo
Name in Chinese Characters /
KATAKANA (if applicable)
(Within 40mm x 40mm)
Date of Birth
Gender
YY/MM/DD
Nationality / Nationalities
Country of Birth
Address
Permanent Address
Zip Code
Phone
Fax
E-mail
Name
Relationship to the
applicant
Address
Emergency Contact
Information
Post Code
Phone
Fax
E-mail
※All nationalities should be listed. Emergency email address should be different from appliant’s.
Official Use Only
願書受付日　受付者　受付番号
1/6
Ⅱ　Educational Background
Name of School
Location
Start date
YY/MM/DD
End date
YY/MM/DD
Elementary Education
Name of School
Location
Start date
YY/MM/DD
End date
YY/MM/DD
Name of School
Location
Start date
YY/MM/DD
YY/MM/DD
Secondary Education End date
(Including High School) Name of School
Location
Start date
YY/MM/DD
End date
YY/MM/DD
Name of School
Tertiary
Post-Secondary
Location
Start date
YY/MM/DD
End date
YY/MM/DD
Name of School
Tertiary
University
Location
Start date
YY/MM/DD
End date
YY/MM/DD
Name of School
Location
Others
Start date
YY/MM/DD
End date
YY/MM/DD
※Please add additional pages for your educational background if necessary.
Ⅲ Qualifications
Subject /
Score
Subject /
International Baccalaureate
Score
Subject /
SAT and High School Diploma
Score
Subject /
ACT
Score
Others
(Please specify.)
GCE ‘A’ Levels
Secondary School
Studies
International
Qualifications
Subject /
Score
Date of Exam
YY / MM / DD
Date of Exam
YY / MM / DD
Date of Exam
YY / MM / DD
Date of Exam
YY / MM / DD
Date of Exam
YY / MM / DD
2/6
Ⅳ Language Proficiency
First language
Is English your first language?
→　If not, please fill in any of the corresponding fields.
English
GCE‘A’level or IB higher
Score
TOEFL
Score
IELTS
Score
Date of Exam
YY / MM / DD
Date of Exam
YY / MM / DD
Date of Exam
YY / MM / DD
Score
Date of Exam
YY / MM / DD
Others
(Please specify.)
Ⅴ Financial Support
How will you support
yourself financially in
Japan?
Self
JPY /month
(e.g. bank loan)
Family
JPY / month
Ⅵ How did you hear about this program?
Answer
Ⅶ Disclaimer and Signature
I hereby declare that all the information provided is true and correct, and the submitted documents contain no forgeries.
Should any forgeries or untrue information be found before or after enrolment,
I understand that any acceptance may be revoked, and no appeals will be allowed under any circumstances.
私、志願者は、以上の記載内容に相違なく、提出書類にいかなる偽造もないこと、またもし万が一合格後にこれらに誤りや偽装が
見つかった場合、合格が取り消されることを理解し、そのことに対するいかなる申し立てをしないことをここに誓います。
I agree to:
私は以下のことに同意します。
●　Comply with the rules on admission, enrolment, fee payment and refunds of Osaka University.
大阪大学による入学者選考、入学、授業料支払い返金の規定に従います。
●　Notify Osaka University International College Office if there are any changes of information
I have given in this application for admission.
出願書類の情報に変更が生じた場合、すみやかにインターナショナルカレッジオフィスに連絡します。
●　Permit Osaka University to access my academic records from other institutions.
大阪大学が私の学歴について教育機関に問い合わせを行うことを了承します。
●　Permit Osaka University to disclose personal information collected from the application form to the
relevant bodies for verification and assessment of previous qualifications.
大阪大学が私の前所属教育機関に本出願書類中の私の個人情報を開示し確認を行うことを了承します。
Signature of Applicant
志願者署名
Date
日付
If applicant is under 20
志願者が20歳以下の場合
Name of Guardian
保護者氏名
Relationship to the Applicant
志願者との関係
Signature of Guardian
保護者署名
Date
日付
3/6
Ⅷ Statement of Purpose
1. Describe why you wish
to study in ChemistryBiology Combined Major
Program.
*Approximately 500-1000
words in English.
4/6
2. Describe your strengths
(in terms of extracurricular
activities, volunteer
activities, qualification
acquisition, etc).
*Approximately 500-1000
words in English.
5/6
Please paste here a copy of the payment certificate of the application fee.
6/6

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