Title: APPLICATION FORM FOR HITACHI SCHOLARSHIP
Author: 日立国際奨学財団
Last saved by: USER
Company: (株)日立製作所

The Hitachi Global Foundation

Application Form for Hitachi Research Fellowship

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 Fellowship
Place of Research:                                                   	
Period(*): From         	To        	
                       (Year)  (Month)  (Day)                 (Year)  (Month)  (Day)
*To propose the period, please consider that the result of selection will be announced by the end of May 2016 and the fellowship program should be completed by the end of March 2017.
Japanese Host Scientist
Name: 		
Title or Position: 		
Institute: 		
E-Mail Address:  	 
Reason for Proposal

		
		
Relation with Proposed Host Scientist

		

Educational Background
Name of School | Place/Country | Degree | Year | Field | Financed by

Honors Awarded:                         	

Language Ability 
1. Please evaluate your language ability by Excellent, Good, Fair or Poor.
| Reading | Writing | Listening | Speaking
English | | | |
Japanese | | | |
2. Please describe how long and where you have studied English and Japanese.  
| Institute | Location | Period
English | | |
Japanese | | |
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 Past Entry into / Stay in Japan
No. of Times                                    
Former Stay in Japan
Location | Period (YY/MM – YY/MM)

Work Experience

School/Institution
(Location)

Period
(YY/MM – YY/MM)

Position

Type of Work

Field of Specialization

Outline of Current Research
   Title: 	
   Contents

   		

   		

Major Publication:  Please attach the list.
 
Proposed Research Plan in Japan (Please attach a proposed schedule as well.)

   Title:          	
   Summary

   		

   		

   		

   		

   		

   Goal and Significance of Proposed Research

   		

   		

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

   		

Are you planning to be accompanied by any dependent? If yes, please indicate their names and relationship.
Name (Family/First/Middle) | Relation

                            Date:     	

                            Signature:

2016 HITACHI RESEARCH FELLOWSHIP