Application for International Graduate Program（Ｃ）(overseas application）

Commencing in October 2011 （Tokyo Institute of Technology【CHECK SHEET】

Name in full（family name, first name) Nationality

【Intended Program】
＊ Please fill in the name of your intended department. As for the department of each program, please refer to the
application guide.
Intended Department：

＊ Please check your intended degree program. As for your choice, please refer to the application guide.
□ Master’s program □ Doctoral program

＊ Please fill in the name of your intended academic advisor (Prior to sending the application, you should
obtain the consent of a faculty member who has agreed to be an academic advisor, in the event of
acceptance into this program).
Intended academic advisor：

【How to apply】
１）Applicants living outside Japan wishing to enroll in the International Graduate Program should
carefully read the Application Guide before applying.
２）Applicants are required to get in touch with their preferred academic advisor. Prior to sending the
application to the Admission Division, applicants should obtain the consent of a faculty member who
has agreed to be an academic advisor, in the event of acceptance into this program.
The following explains how to find an academic advisor.
First, applicants should check the list of faculties and look for a faculty member who is willing to
be an academic advisor.
Second, applicants should directly contact the intended academic advisor by e-mail and include
their CV (curriculum vitae), academic transcripts, future research plans and scores from TOEFL-iBT,
TOEFL-PBT, TOEIC or IELTS academic module. For more information on our faculty members, such
as e-mail addresses, etc., applicants can refer to our “Researchers’ Database”.
※ Only if applicants fall under eligibility condition (3) for Master’s or Doctoral Program they are
requested to submit the “Application form for individual adjudication of admission eligibility”
with their research achievement and outline of research to date before submitting the formal
application. Please see the explanation "３.Eligibility" in the application guide.
３) Applicants must pay the application fee within the application period and submit the “Certificate
of Payment (receipt)” or “the printed result page ”on the website with other application documents.
Please see the details about the payment methods mentioned below.
４) The completed application documents must reach the Admission Division no later than May 27,
2011 by postal mail.
*However, some academic advisors may require the applicant to submit the additional documents
before the deadline. Applicants must check the program web page and make inquiries to his/her academic
advisor about the program.
【Announcements】
Notification of admission will be posted to all applicants in mid- July, 2011.
Applicant’s address, telephone and facsimile number, E-mail address on and after mid-July.

Applicant’s name :
Address:

Phone number:
Facsimile number:
E-mail:

【Attention】
If you change your address after applying, please inform the Admission Division at Tokyo Institute of Technology.
【Application Requirements】

Please check the following boxes（□） and submit these application requirements by the deadline.

□ １.Completed application form (attached form) (original, not photocopied)

□ ２. Field of study and study program (attached form)

□ ３. Official academic transcripts from each undergraduate and graduate school(original or certified copy)

□ ４. Certificate of graduation or expected graduation from each undergraduate and graduate school (original
or certified copy)
*If you are graduating early or have skipped a grade, please submit an official document or letter issued by
the school indicating this fact.

□ ５. Summary of thesis
*Undergraduate program students: an outline of your study or research.
**Master’s program students: the details of your Master’s program research in an unprescribed format.

□ ６. English Proficiency Test(original, not photocopied)

*Scores from TOEFL-iBT, TOEFL-PBT, TOEIC or the IELTS academic module taken within two years
before the application deadline. Applicants whose first language is not English must submit TOEFL, TOEIC
or IELTS scores. Score sheets from TOEFL-ITP, TOEIC-IP and other tests conducted through a special group
system are not acceptable. We do not take any responsibility for a late score, so it is necessary for applicants to
make preparations well in advance in order to submit the score by the application deadline.
**Tokyo Institute of Technology’s institution code number for TOEFL is “0215”.

⇒ Please be sure to check the following box when you have requested ETS/British Council to send an official
score sheet directly to Admission Division, and write down the “test date”. Tokyo Tech’s institution code
number for TOEFL is “0215”.
□ TOEFL (test date: . . )
□ IELTS (test date: . . )

□ ７. Evaluation sheet with a recommendation letter from a supervisor, head of department, etc. to verify the
potential of the applicant（attached form) (original, not photocopied)

□ ８. One copy of the applicant’s passport(page showing name, nationality and photo)

□ ９. Application Fee(¥ 30,000 (JPY))

Applicants must pay the fee within the application period by using one of the following methods.
① Online payment using credit cards → Please see the online payment website
（https://e-shiharai.net/english/）.
② Overseas remittances → Please make the payment in Japanese yen and remit 30,000 yen as the
application fee to the designated bank account. The remittance fee, commissions including lifting charges
or handling fees will be the responsibility of the applicant.

(Bank Information)
Bank Name : Sumitomo Mitsui Banking Corporation (Mitsui-Sumitomo-Ginkou)
Branch Name: Tokyo Public Institutions Operations Office (Tokyo-Koumu-Bu)
Account No. : Savings Account (Futsu Yokin) No. 152218
Account Name : Tokyo Institute of Technology-Gakunoukin
Address : 2-12-1 O-okayama, Meguro-ku, Tokyo 152-8550
Swift Code : SMBC JP JT
※ Please fill in“your full name and application fee”on remarks column.

Please attach “ the Certificate of Payment (receipt) ” or “ the printed result page ”on the website to other
application documents whichever method you choose. We do not accept any CASH or CHECKS.
□ １０．Scholarship Application documents
Master’s program applicants who wish to apply for the scholarship listed below
(“７.Scholarship”) are required to prepare the necessary documentation and enclose these
documents with other application documents listed above(No.1～9). Before applying for the
scholarship, applicants are required to check the application qualifications carefully on the
sholarship information website first. Please see the explanation “７．Scholarship”in the
application guide.

【Scholarship】
Scholarships listed below will be offered to Master’s program applicants for IGP(C) with outstanding
academic records through the recommendation of Tokyo Institute of Technology. The information is
available on the following website:
http://www.gakumu.titech.ac.jp/nyusi/igp/c_1110_guide/scholarship_1110c.html

If you are interested in these scholarships, please check the application qualifications carefully on
the website first. Then, if you wish to apply for one of them, download its application form from the
site, complete it, and enclose it with the other required application documents (Documents #1 to 9 on
the previous page). Additionally, please check the following checkbox to indicate your intention to
apply for the scholarship. If you wish to apply for more than one scholarship at a time, you should
number your preference (1, 2, etc.)
□ Konica Minolta Scholarship (Preference )
□ Bridgestone/Tokyo Tech Scholarship (Preference )
□ NTT Docomo Scholarship (Preference )
□ Any other scholarship that might be available, even if only a small amount.
Please state if you will receive any financial assistance from any organization to support your study in
Japan, and if so, the name of the organization and amount of monthly stipend.

Please note that your official academic transcripts should carry cumulative GPA if you wish to apply
for the scholarship. The result of scholarship selection will be sent to all applicants. The time of
notification will be different for each scholarship. Please see the above website for details.

【NOTE】
1) Please note that we will not accept any documents after the deadline, and that incomplete
applications will not be accepted.
2) Original documents written in any language other than English must be accompanied by an
English or Japanese translation certified by a public institution or the university issuing the original
documents.
3) Original documents written in any language other than English must be accompanied by an
English or Japanese translation certified by a public institution or the university that issued the
original documents.
4) The submitted documents will not be returned under any condition. Please keep a copy of all
documents for your own reference.
5) Admission may be withdrawn if the application documents are found to be false or they contain
false information.
Admission Division
Student Service Department
Tokyo Institute of Technology
2-12-1,O-okayama,Meguro-ku,Tokyo 152-8550
JAPAN
Tel:＋81-3-5734-3024
Fax:＋81-3-5734-3676
E-mail: ryugakusei＠jim.titech.ac.jp
 A P P L I C AT I O N F O R A D M I S S I O N T O I N T E R N AT I O N A L G R A D U AT E P R O G R A M （ C ）
C O M M E N C I N G Ｉ Ｎ Ｏ Ｃ Ｔ Ｏ Ｂ Ｅ Ｒ 2 0 11 T O K Y O I N S T I T U T E O F T E C H N O L O G Y
平 成 ２３年 １０月 入 学 東京工業大学 国 際 大 学 院 プログラム(Ｃ)入 学 申 請 書

ＩＮＳＴＲＵＣＴＩＯＮＳ（記入上の注意）
１．The application should be typed if possible, or neatly handwritten in block letters. （明瞭に記入すること｡)
２．Numbers should be in Arabic numerals.（数字は算用数字を用いること｡)
３．Years should be written using the Anno Domini system. （年号はすべて西暦とすること｡)
４．Proper nouns should be written in full and not abbreviated. （固有名詞はすべて正式な名称とし，一切省略しないこと｡)

(Sex)
１．Name in full in native language □Male（男）
，
（姓名（自国語)) (Family name) (First name) (Middle name) □Female（女）

In Roman block capitals (Marital Status)

，
（ローマ字） (Family name) (First name) (Middle name) □Single（未婚）
□Married(既婚)
２．Nationality
（国 籍）

Paste a passport photograph

３．Date of birth(生年月日） taken within the past 6 months.
19 Write your name and nationality
Year（年） Month（月） Day（日） in block letters on the back of the

photo.
４．Present status with the name of the university attended or employer （4.5cm×3.5cm photo）
（現職（在学大学名又は勤務先名まで記入すること｡）） (写真(4.5cm×3.5cm))

５．Present address and telephone number, facsimile number, e-mail address

（現住所及び電話，ファックス番号，E-mail アドレス）

現住所(Present address）：

電話番号/FAX 番号(Telephone/facsimile number）

：

E-mail address：

* If possible, write an e-mail address that can be used for periods including the time before you come to Japan, your stay in Japan and the period after
you return home.
（可能な限り、渡日前～日本留学中～帰国後にわたり使い続けることが予想される E-mail アドレスを記入すること。）

６．Field of specialization studied in the past（Be as detailed and specific as possible.)

（過去に専攻した専門分野（できるだけ具体的に詳細に書くこと｡））

７．Field of study in Japan (日本の希望専攻分野)

（Detailed field of study（研究分野（詳細））

－1－
８．Educational background （学歴）

Name and Address of School Year and Month Amount of time Diploma or Degree awarded,
of Entrance and spent at the Major subject
Completion school attended
（学校名及び所在地） (入学及び卒業年月) （修学年数） （学位・資格，専攻科目）

Name From years

(学校名) （入学） （年）
Elementary Education
(初等教育)
Location To and
Elementary School (所在地) （卒業） months
（小学校） （月）

Name From years

(学校名) （入学） （年）
Secondary Education
（中等教育）
Location To and
Lower Secondary School (所在地) （卒業） months
（中学） （月）

Name From years

(学校名) （入学） （年）

Upper Secondary School

（高校） Location To and
(所在地) （卒業） months
（月）

Name From years

(学校名) （入学） （年）
Higher Education
（高等教育）
Location To and
Undergraduate Level (所在地) （卒業） months
（大学） （月）

Name From years

(学校名) （入学） （年）

Graduate Level
（大学院） Location To and
(所在地) （卒業） months
（月）

Total years of schooling mentioned above

years
（以上を通算した全学校教育修学年数）
（年）

* If the blank spaces above are not sufficient for the information required, please attach a separate sheet．
((注) 上欄に書ききれない場合には，適当な別紙に記入して添付すること｡)

９．State the titles or subjects of books or papers (including graduation thesis authored by the applicant), if any, with the name and address of the publisher and
the date of publication.
（著書，論文（卒業論文を含む｡）があればその題名，出版社名，出版年月日，出版場所を記すこと｡）

* Please attach abstracts of those papers to this application.

（(注)論文の概要を添付のこと｡）

－2－
10．Employment Record: Begin with the most recent employment, if applicable.（職歴）

Name and address of organization Period of employment Position Type of work

（勤務先及び所在地） （勤務期間） （役職名） （職務内容）

From
To

From
To

11．Japanese language proficiency: Evaluate your level and insert an X where appropriate in the following blank space.
（日本語能力を自己評価のうえ，該当欄に×印を記入すること｡）
Excellent Good Fair Poor
（優） （良） （可） （不可）
Reading
（読む能力）
Writing
（書く能力）
Speaking
（話す能力）

12．Foreign language proficiency: Evaluate your level and insert an X where appropriate in the following blank space.
（外国語能力を自己評価のうえ，該当欄に×印を記入すること｡）
Excellent Good Fair Poor
（優） （良） （可） （不可）
English
（英語）
French
（仏語）
German
（独語）
Spanish
（西語）

13．Accompanying Dependents (Provide the following information if you plan to bring any family members to Japan.)
同伴家族欄（渡日する場合，同伴予定の家族がいる場合に記入すること。）
* All expenses incurred by the presence of dependents must be borne by the grantee. He/She is advised to take into consideration various difficulties and
the great expense that will be involved in finding living quarters. Therefore, those who wish to be accompanied by their families are advised to come alone
first and let their dependents come after suitable accommodation has been found.

( )
（注）なお同伴者に必要な経費はすべて留学生の負担であるが，家族用の宿舎をみつけることは相当困難であり賃貸料も非常に割高になるの
であらかじめ承知されたい。このため，留学生はまず単身で来日し，適当な宿舎をみつけた後，家族を呼び寄せること。

Name Relationship Age

（氏 名） (続 柄) （年 齢）

－3－
14. Person to be notified in applicant's home country in case of emergency:
(緊急の際の母国の連絡先)
ⅰ） Name in full:
（氏名）
ⅱ） Address: with telephone number, facsimile number, e-mail address
（住所：電話番号，ファックス番号及び E-mail アドレスを記入のこと｡）

現住所(Present address)：

電話番号/FAX 番号(Telephone/Facsimile number）：

E-mail address：

ⅲ） Occupation:
（職 業）
ⅳ） Relationship:
（本人との関係）

15.Immigration Records to Japan（日本への渡航記録）

Date（日付） Purpose（渡航目的）

From

To

From

To

16．Term you wish to study in Japan（日本における希望留学期間）

a) Only a research student’s term Maximum period of One year and six months) 研究生のみ（最長１年６ヶ月）

b)By the end of master’s degree course completion( Years) 修士課程修了まで（ 年間）

c) By the end of doctoral course completion( Years) 博士課程修了まで（ 年間）

d) By the end of professional graduate course completion( Years) 専門職学位課程修了まで（ 年間）

Date of application:
（申請年月日）

Applicant's signature:
（申請者署名）

Applicant's name
（in Roman block capitals）：
（申請者氏名）

－4－
（別紙）

専攻分野及び研究計画
Field of Study and Study Program

Full name in native language

，
（姓名（自国語）） (Family name) (First name) (Middle name)

Nationality
（国 籍）

Proposed study program in Japan (State the outline of your major field of study on this side and the details of your study program on the backside of this
sheet in concreteness. This section will be used as one of the most important references for selection. Statement must be typewritten or written in block
letters. Additional sheets of paper may be attached if necessary.)

( )
日本での研究計画；この研究計画は，選考の重要な参考となるので，表面に専攻分野の概要を，裏面に研究計画の詳細を具体に記入すること。
記入はタイプ又は楷書によるものとし，必要な場合は別紙を追加してもよい。

If you have Japanese language ability, write in Japanese.

（相当の日本語能力を有する者は，日本語により記入すること｡）

１ Field of study（専攻分野）
２ Study program in Japan in detail and concreteness（研究計画：詳細かつ具体に記入すること｡）
 TOKYO INSTITUTE OF TECHNOLOGY
Evaluation sheet with a recommendation letter
to verify the potential of the applicant
This form should be completed by a supervisor, a Department Head or an appropriate person
who knows the applicant well.
To the Applicant
Applicant completes only the top section of this form.

Last name（family） First name Middle name

Waiver
One recommendation must be submitted from the last institution attended for full time study.
Students may waive their right to access recommendations. The following signed statement
indicates the intention of the applicant regarding this recommendation.

□ I DO WAIVE my right to inspect the contents of the following recommendation.

□ I DO NOT WAIVE my right to inspect the contents of the following recommendation.

SIGNATURE

Name of recommender :
Title and Institution :

To the Recommender
Recommender should complete this part of form. Please print or type.

I have known this applicant for years.

During this time, the applicant was : □ an undergraduate student □ a graduate student

□ an advisee of mine □ other (please specify)

On the following scales, please rate the applicant in relation to others in the same year in your
department/university.The rating should reflect the applicant’s academic record and other objective
data.
Top 2％ Top 5％ Top l0％ Top 20％ Middle 50％
Truly Exceptional Excellent Very Good Good Average

Academic Performance □ □ □ □ □
Intellectual Potential □ □ □ □ □
Creativity and Originality □ □ □ □ □
Maturity □ □ □ □ □
Ability to work with others □ □ □ □ □

Japanese Proficiency : □ excellent □ fair □ poor

Please continue on the reverse side.

Instructions :
The Graduate School would appreciate a statement from you concerning this applicant. Please
write candidly and analytically about the student’s qualifications and potential to carry out
advanced study in the field specified. Highlighting both strong and weak points will be helpful in
describing such attributes as motivation, intellect, maturity, and other relevant characteristics.
Specific examples are far more useful than generalizations. Please compare the applicant with
the others whom you have recommended to or known at the Graduate School at Tokyo Institute
of Technology and/or other institutions. If you prefer to write a letter instead, please attach it to
this form. Thank you for your assistance.

In summary, my recommendation for this applicant is :

□ very strong □ strong □ average □ below average

Confidentiality
This recommendation remains confidential during the admission process. If the applicant has not
signed the waiver of right to inspect the recommendation, your evaluation will become accessible
as part of the education record only if the applicant enrolls in the Graduate School.

Person recommending the applicant:

Position or Title : E-mail:
Institution :
Address

Signature: Date

Mailing Instructions : Please enclose this form, sign across the seal, and return it to the applicant
for enclosure with the application form．Thank you．
Admission Division,
Tokyo Institute of Technology