Application Form for Hitachi Scholarship

Name: 	  	  	
            (Family Name)                   (First Name)                 (Middle Name)

Photo taken within the past 6 months
without hat

3cm x 4cm

Nationality: 	
Date of Birth:                          Age: 	
　　　　　　　   (Year)  (Month)  (Day)
Sex (circle): 	Male   or	Female
Marital Status (circle): 	Single   or	Married
Current Title/ Position in University: 	
Department/ Faculty: 	
Address (University): 	
	   	
Home Address:       	
           	
TEL:                                  	
                (Office)                                    (Mobile Phone)              
FAX:                               E-Mail Address: 	
                (Office)            
Contact in case of Emergency
Name & Relation:                                  　　　           	
TEL/FAX/E-Mail:                                                   	
Proposal on School/Course/Period/Host Scientist
Intended Graduate School
Name:		
Department:		
Major:		
Period
From		  To 	
No. of Years	           	
Entrance Exam (circle):    Required   or   Not Required
Timing and Location of the Exam if required: 			
Japanese Host Scientist
Name:                                                         	
Title or Position:                                                 	
E-Mail Address: 	
	
Reason for Selection of Host Scientist/Graduate School

		

		

Supervisor in Home University
Name:                                                          	
Title or Position:                                                  	
Educational Background (from primary school)

Name of School	
Place/Country	Period 
(YY/MM – YY/MM)	
Degree	
Financed by	
		–			
		–			
		–			
		–			
		–			
		–			
Honors Awarded:                         	

English Language Ability
1. Please evaluate your English language ability by Excellent, Good, Fair or Poor.
	Reading	Writing	Listening	Speaking	
Ability					
2. Please describe how long and where you have studied English.  
Period of Study:      	
Location and Institute: 	
3. Please describe your score if you have taken the Test of English as a Foreign Language (TOEFL) or similar test. 
Score: 	
When: 			
                     (Year)                        (Month)

Record of Study of Japanese Language, if any
	Institute	Location	Period of Study	
1				
2				
Record of Past Entry into / Stay in Japan
No. of Times                                    
Physical Condition (circle)
	Excellent        Good        Fair        Poor
Work Experience
School/Institution
(Location)	Period
(YY/MM – YY/MM)	Position	Type of Work	

				

Family:  Please fill in all the names of your family, i.e. your spouse, children, parents, brothers and sisters including the deceased.  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.
Full Name	Relation	Age	Occupation	

	

Proposed plan of study or research:  Please describe in detail.
   Title:                            	
   Contents

   		

   		

   		

   		

   		

Plan after completion of study or research at the graduate school

   		

   		

Are you applying for any scholarship other than Hitachi Scholarship?  If yes, please indicate to which scholarship the application has been made.

   		

                            Date:     	

                            Signature: