Form #1

Application MEM International Graduate Program

Please check:
1. Department Mechanical Engineering Electrical Engineering and Information Systems Materials Engineering Aeronautics and Astronautics

Chemical System Engineering 2. Course Master Ph.D.

3. The name of the prospective supervising faculty member from whom you received the acceptance letter. Name: ___________________________________________________________________ 4. Are you applying for the Scholarship provided by MEM International Graduate Program? 1. 2. Yes, and I will not enroll if I do not receive the Scholarship provided by MEM International Graduate Program. Yes, and I plan to enroll even if I do not receive the Scholarship provided by MEM International Graduate Program. If you checked Number 2, do you plan to apply for financial support from the other sources in case you do not receive the Scholarship provided by MEM International Graduate Program? Yes. What other source? ____________________________ No. I will be a self-financed student. 3. No. I am not applying for the Scholarship provided by MEM International Graduate Program. If you checked Number 3, do you have financial support from the other sources? Yes. What other source? ____________________________ No. I will be a self-financed student.

Please type or write in Japanese / in English block letters.

1. Name:____________________________________________________________ Family name First name Middle name 2. Date of birth: _________________ Mr. Ms.

3. Age (as of 1 April 2014): _____ 4. Nationality: ___________________ 5. Marital status: Single Married

6. Present status: with the name of the University or of the employer _______________________________________________ 7. Correspondence address: ______________________________________________________________ ______________________________________________________________ E-mail address: ____________________ Valid until: _____________________ Phone number: _____________________ Valid until: _____________________ Fax number: _______________________ Valid until: _____________________ 8. Permanent address(if different): ______________________________________________________________ ______________________________________________________________ Phone number: _____________________ Valid until: _____________________ Fax number: _______________________ Valid until: _____________________ 9. GPA (Grade Point Average) Bachelor: _____________ Masters: _____________ 10. Educational background

Name and Address of School Elementary School

Year and Month of Entrance and Completion From To From

Diploma or Major Degree Subject awarded

Middle School

To From

High School

To From To From

Higher Education Undergraduate Level

Graduate Level Total years of school

To

11. Employment Record. Please list your current and previous employment in chronological order, putting your present or most recent post first. Name and address of period of employment Position held Type of work organization

12. Research activities in the past:

13. Describe subject and plan of research you would like to pursue, if you are admitted to the MEM International Graduate Program.

Research Subject

Research Plan

Purpose for pursuing the Doctoral degree or the Master's degree in the proposed research topic.

Reasons for choosing the prospective supervising professor.

14. Foreign Language Proficiency: Excellent English French German Spanish

Good

Poor

Reading Japanese Writing Speaking 15. If you have applied or you are to apply for admission to the university other than The University of Tokyo, please write the name of the university. ___________________________________________________________________