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(4 x 3 cm)

Internship Form A-1

SHORT STAY PROGRAM

Internship Program of International Center

at Tokyo University of Agriculture and Technology

(AIMS-SS)Please fill in Item 1 to 10 by the applicant. Date of application 1 10 !"#$%&'()*+,-./ Year Month Day

20 0 1 2

Director of International Center

Tokyo University of Agriculture and Technology

3 4

I wish to apply for admission as an internship student to your university.

56*7/89:;?@ABCDEF,G

1. Name in full in native language H same as in your passportI

HJK INOPQR*/ST

(Surname) (First) (Middle)

In Roman block capitals H same as in your passportI

HVWI

(Surname) (First) (Middle)

2. Nationality

HXI

3.Your own e-mail address (Please print clearly.)

HYZ[\]^_OI

`

4. Present status: Name of the home institution and faculty

HabaXcKdI

5.Date of birth

APPLICATION FOR

ADMISSION

(Taken within thelast 3 months)

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He012I Year 19 Month Day

(0 ) H1I H2I

6. Place of birth (Names of province and city)

(If you are Chinese, please write in Chinese characters.)

HDefI

Internship Form A-2

7. Sex g Male g Female

Hh;I

8. Passport information (if available)

HNOPQ=iI

Number: Date of issue:

Issuing authority: Date of expiration:

Do you have a Japanese nationality simultaneously (dual nationality)?gYesgNo

If you have a passport, its copy should be attached to the application form.

9. Contact addresses (Please print clearly.)

H>jkI

1) Current address of the applicant

HlmnI

Address

Zip Code /Area Code (if you have)

Phone Fax

E-mail

2) Mail address if different from your current address

HopkI

Address

Zip Code /Area Code (if you have)

Phone Fax

3) Home address (if different from your current address)

Hqr7mnI

Address

Zip Code /Area Code (if you have)

Phone Fax

E-mail

4) Contact address in case of emergency after you leave for Japan

Hstu7>jkI

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Person to contact

Address

Zip Code /Area Code (if you have)

Phone Fax

E-mail

10. Term of internship in TUAT

HvwI

From Year 20 Month Day

To Year 20 Month Day

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Internship Form A-3

11. Recommendation Please have your academic advisor fill out.HxyzI aX7{|}~)*+FCG

I recommend this applicant for Internship Program of International Center

at Tokyo University of Agriculture and Technology. I guarantee this applicant to

be in good physical and mental health, free of any chronic conditions, disorders orcontagious diseases, and capable physically and mentally of completing the

program.

Academic Advisors Name

Advisors Affiliation

Academic Advisors Signature

I certify that all the information provided in this form and the accompanying documents is

complete and accurate to the best of my knowledge, and if admitted, I agree to comply

with the rules and regulations of Tokyo University of Agriculture and Technology and the

Japanese domestic law.

I will also carry comprehensive health insurance valid in Japan, e.g. travel insurance.

Date ! ! "# $ignature of ApplicantDay !%onth !&ear

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Questionnaire

Name

University

Faculty (or School or College)

Department (or Program or Major)

Explain your field of study within 6 keywords

,

,

,

Is there anything you cant eat?

If you have any comments, please quote.