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 Japanese Government's MEXT Scholarship?
   1. Yes, and I will not enroll if I do not receive the MEXT Scholarship.
   2. Yes, and I plan to enroll even if I do not receive the MEXT Scholarship.

      If you checked Number 2, do you plan to apply for financial support from the other sources in case you do not receive the MEXT Scholarship?

      • Yes. What other source? ____________________________
      • No. I will be a self-financed student.
   3. No. I am not applying for the MEXT Scholarship.

      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:____________________________________________________________ Mr. Ms.
   
   • Family name
   • First name
   • Middle name
2. Date of birth: _________________
3. Age (as of 1 April 2010): _____
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	Year and Month of Entrance and Completion	Major Subject	Diploma or Degree awarded
    Elementary School		From To
    Middle School		From To
    High School		From To
    Higher Education Undergraduate Level		From To
    Graduate Level		From To
    Total years of school

    
    
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 organization	period of employment	Position held	Type of work

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	Good	Poor
    English
    French
    German
    Spanish
    Japanese	Reading
    	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.
    ___________________________________________________________________