To: Rotary Yoneyama Memorial Foundation

To: Rotary Yoneyama Memorial Foundation

※Please fill out this form in Japanese or English. PLEASE TYPEOR PRINT CLEARLY.

※If you have Japanese proficiency, writing in Japanese is preferable.

※APPLICATION DEADLINE IS MONDAY OCTOBER 16, 2017 ON 1P.M. JAPAN TIME.

※Please check (レ) the appropriate items.

Application for Scholarship

Rotary Yoneyama Scholarship for Applicants Residing Abroad

For overseas students scheduled to enroll in April or fall2018in a Japanese university or graduate school. Under Japan’s pre-arrival university admission system is preferable.

1. Personal information

Name
Birth
date / Family nameFirst name Middle name
Y ear Month Day / Gender / □Male □Female
Nationality / Birthplace
Country・City
Address
Telephone # / FAX #
Cellular phone # / E-mail address

1. The university or graduate school , spring or autumn admission to which you are applying

(1)Please tick (レ) the appropriate items in the □.

□　University Bachelor’s degree □Spring admission□autumn admission

□　Graduate School Master’s degree □Spring admission□autumn admission

□　Graduate School Doctoral degree □Spring admission□autumn admission

*Reserch Students are not eligble.

(2)Name of university or graduate schoolin Japan (school of your choice)

(3)Major field/course

(4)Name of the applicant’s faculty advisor of your enrollmentin Japan.

(Or name of the admission office you are applying)

If you don’t fill this out, your application can’t be accepted.

Name

Tel: (Japan)

(5)Location :

Please make sure and write down the campus you will go.

1. Past entry into/depature from Japan

Have you entered or left Japan in the past? □ No □Yes( times)

Fill in the following if your answer is “Yes”

Dates entered
Year Month Day / Dates departed
Year Month Day / Visa Status / Purpose of Visit
1
2
3
4

1. Your education

Please fill in your academic background from the elementary school to the current school you are attending.Please also include schools such as a Japanese language school, professional school and/or university if you were enrolled in one as a research student.

Course / Year and month entered & completed / Name of school / Address
Country・city only / Diplomat acquired, etc
Elementary school / From year month
To year month
Junior high school / From year month
To year month
Senior high school / From year month
To year month
Higher educational institution than high school. / From year month
To year month
From year month
To year month
From year month
To year month
From year month
To year month

1. Your emplyment history

Name of corporations in which you have worked / Address (country & city only) / Job title / Length of employment
From year month
To year month
From year month
To year month
From year month
To year month

1. Foreign language study

Foreign Language / Proficiency level / Year & month certificate issued
Japanese / □Poor □Fair □Good □Excellent
English / □Poor □Fair □Good □Excellent / Your test score of TOEFL, IELTSorTOEIC
Other languages
(specify) / □Poor □Fair □Good □Excellent
□Poor □Fair □Good □Excellent

(1)Levels of foreign language proficiency

(2)Have you studied Japanese before?

□ No □Yes Fill in the following if your answer is “Yes”

Name of institution, Japanese language school / Location / Dates from
Year Month / Dates to
Year Month

(3)Have you taken a JapaneseLanguage Proficiency Test?

□ No □Yes Level： ．

Persons who have taken the Japanese Language Proficiency Test are asked to provide the test results. If No, don’t need to submit the copy.

1. About your family members

Family (father, mother, spouse, son, daughter, brother, sister or others)

Name / Relation-ship / Age / Intends to reside with applicant or not / Name of employer/school / Nationality
Father / □Yes □No
Mother / □Yes □No
Spouse / □Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No

1. Self-Assessment

※ Please fill out in Japanese or English PLEASE TYPE OR PRINT CLEARLY. DON’T USE CURSIVE HANDWRITING.

■Your interests

■Self-analysis

Your strong points
Your weak points
Your favorite school subject(s)

■Outline of your intended studies in Japan

■Your plans after having completed your studies in Japan

■Minor composition: “My motive for applying for this scholarship”

The above contents constitute my self-introduction, which information I swear to be based on my own views and to be true and accurate.

Date: Year___ Month___ Day___

Signature: hand-write ______

Name in block

*This signature should be made with hand-write and submit by PDF.

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※Please acknowledge that the information you provide here will be treated as personal data, kept in secure custody, and distributed to selectioncommittee members for use as reference in applicant screening.