(This application form should be written clearly and completed in English. Typing is preferable)

SECTION 1 - PERsonal Information
Applicant Name:
______
Last name First name Middle name / ID Photo 3 x 4cm
Gender Male £ Female £ / Date of birth Month:____ Date_____ Year_____
Present Address
Residence - Street Address - City/Province / Telephone:
Mobile:
Permanent Address
Residence - Street Address - City/Province / Email address:
Preferred contact address: (can √ tick more than one)
£ Present Address £ Permanent Address £ Email £ Telephone £ Mobile
Section 2 - Education
A.  Current University
Name of university / Student ID
Department/Faculty / Major of Study
Current Academic Year £ First £ Second £ Third £ Fourth £Fifth
Academic record :

the 2nd semester of the last academic year :

the 1st semester of the current academic year: / Talent Class:
£ Yes £ No
B.  GenerAL
1. Honors/Awards/Scholarship History (Include amounts and effective dates )
From (DD/MM/YY) / To(DD/MM/YY) / Name/Description of Scholarship
2. List of practical project activities/workshops/ science papers in which you were involved:
(Please attach (1) cover page and appendix of workshop/appendix of journal/ conference proceeding in which the paper is published/ presented; and (2) a copy of research paper.
From (DD/MM/YY) / To (DD/MM/YY) / Name/Description of projects/workshops/ science papers
3. Extracurricular/Community Activities (Include school and community activities in order of importance)
From (DD/MM/YY) / To(DD/MM/YY) / Name/Description of Activities
4. English language skills
Speaking / Listening / Writing / Reading
£ Excellent £ Good
£ Fair £ Poor / £ Excellent £ Good
£ Fair £ Poor / £ Excellent £ Good
£ Fair £ Poor / £ Excellent £ Good
£ Fair £ Poor
5. Japanese language skills
£ Excellent £ Good
£ Fair £ Poor / £ Excellent £ Good
£ Fair £ Poor / £ Excellent £ Good
£ Fair £ Poor / £ Excellent £ Good
£ Fair £ Poor
SECTION 3 – FAMILY INFORMATION (Father, mother, wife/husband, children, brothers and sisters)
Relative / Full-name / Age / Occupation / Work place or present address
SECTION 4 - SCHOLARSHIP
1.  Have you ever taken a Japanese course?
£ Yes ______No £
(If yes, please attach the certificate(s) of Japanese Proficiency)
2.  Have you ever participated in a movement/ activity aiming at contributing /promoting the exchange of culture between Japan and Vietnam?
£ Yes ______No £
(If yes, please specify or attach certificate(s) of the movement/activity participation)
3.  Have you ever received any scholarship from Kanden-SS Scholarship Fund?
 Yes ______No 
(If yes, please specify the type of scholarship)
4.  Do you agree to participate in Kanden SS’s business?
Strongly agree £ Agree £ No idea £ Disagree £
SECTION 6 – DOCUMENT CHECKLIST
Document checklist: Compulsory
1 / Application form
2 / Academic record of the 2nd semester of the last academic year and of the 1st semester of the current academic year
3 / Letter of Motivation
4 / The most recent research paper of the last academic year
5 / Cover page and appendix of journal/ page of workshop/conference proceeding in which the paper is published/ presented
6 / At least one recommendation letter of the Dean or Head of Department or a Research Supervisor or a Class Head Teacher.
Document checklist: Optional
7 / Certificate of Japanese proficiency
8 / Other awards, honours, certificates (please provide details)

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all the information included in this application and attached documents is complete, correct and true to the best of my knowledge. I authorize the release of information concerning my background, academic and financial status to confirm and verify this application.
Signature: / Date: (day)_____/(month)______/(year)______

Note: Kanden-SS Scholarship Program 2015 will not consider illegible, incomplete application packages, or documents reaching the given address after the deadline (both of original and scan documents). Applications will not be returned.

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