1. education
2. school

Sample
2014年9月/2015年4月入学 早稲田大学
Application No.*
・Fill in
the form基幹・創造・先進理工学研究科
using black or blue ink.（Write accurately in standard style）
大学院
・Please print in black and white when you use MS-Word Version.
外国学生ＡＯ入学試験 志願票
September 2014 and April 2015Entrances
Paste a recent
passport sized
photograph
*Office Use Only
Paste a recent
measuring
3 cm bycolor
4 cm
Application Form for Admission to Graduate Schools of Waseda University,
Admission to International Graduate Program
WASEDA
Name in Alphabet
any
(First)
ワセダ
Name in Chinese characters / Kanji,
*if any
United States of America
Nationality
□ Domestic Applicant
✔ Overseas Applicant
□
measuring 3 cm by 4 cm
passport sized
photograph
Paste
a recent color
measuring 3 cm by 4 cm
passport sized
photograph
measuring 3 cm by 4 cm
RIKO
(Family)
Name in Katakana *if
passport sized
photograph
Write the name printed on your Passport.
<Ⅰ> Applicant information
Paste a recent
color
colorphotos.
Paste only
on the top of the two additional
Gender
早稲田
(Middle)
リコウ
理工
Date of birth
□Male
✔
□Female
19
８７/１０/ ２５
Marital Status
(year / month / day)
□Married
✔
□Single
Home address
X-X-XXXXXXXXXXXXXXXXXX, California USA
Present address
X-X-XXXXXXXXXXXXXXXXXX, New York City USA
E-mail address
gyoumu@sci.waseda.ac.jp
(Tel.
Paste
a recent
Paste
a recent
color
color
passport sized
passport
sized
photograph
photograph
measuring 3 cm by 4 cm
measuring 3 cm by 4 cm
+1-(0)XXX-XXXXXXX-XX )
(Mobile+1-(0)XXX-XXXXXXX-XX)
<Ⅱ> Desired field of study at graduate school
Graduate School
Department
*☑your desired school
Research Instruction
✔Fundamental Science
□
Engineering
Application code
(three-digit)
Main-supervisor
and Engineering
□Creative Science and
Name of supervisor
Mathematical
Pure and Applied Logic and
Mathematics
Set Theory
Prof. EDA Katsuya
Vice-supervisor *if any
A01
□Advanced Science and
Engineering
Note: 1) For the name of supervisor, research instruction and application code, refer to the "List of Areas of Research & Faculty Directory".
2) If you are applying to become a research
student
and youof
do not
wish to receive research
instruction,
you can leave
research
instruction, name of
For the
name
supervisor,
research
instruction
and
application
supervisor, and application code blank.
code; refer to the "List of Areas of Research & Faculty Directory".
<Ⅲ> Desired Programs
*Circle your desired program
Degree Program
Master's Program
Non Degree Program
(Research Student / Master's Program Equivalent)
Degree Program
Doctoral Program
Non Degree Program
(Research Student / Doctoral Program Equivalent)
<Ⅳ> International Student Category *☑your category
✔ Privately financed international student
□
□ Scholarship student expected to receive a scholarship in the amount equivalent of tuition
→□ MEXT scholarship student
(Name of the scholarship:
→□ Ting Hsin International Group, Tingyi (Cayman Islands) Holding Corp. Scholarship
→□ Other scholarship
(Name of the scholarship foundation:
)
)
<Ⅴ> Desired period of admission *☑your desired period
✔ September 2014
□
□ April 2015
1/2
<Ⅵ> Educational background
Note: 1) List all schools attended (including primary school, language schools, etc.) in chronological order.
2) If you have more information to add but have run out of space on the form below, you can attach extra details on a separate sheet of paper.
Name of school
Location of school
●●● Elementary School
USA/California
■■■ Junior High School
USA/California
▲▲▲ High School
USA/California
◎◎◎ University
Department of Mathematics
USA/New York
Period of attendance
1998
(year)
9
(month)
2004
(year)
9
9
to
(month)
2010
(year)
to
(month)
2007
(year)
to
9
to
(month)
Degree
2004
6
(year)
(month)
2007
6
(year)
(month)
2010
6
(year)
(month)
2014
6
(year)
(month)
(year)
(month)
(year)
(month)
(year)
(month)
(year)
(month)
－
－
－
Bachelor
to
(year)
(month)
(year)
(month)
If you are currently
enrolled,
to
(year)
please (month)
write the (year)
expected(month)
date of
to
graduation
attended"
(year)
(month)for "Years
(year)
(month)
For "Name of institution", please write
the name of department or graduate
school in addition to the name of
university.
to
to
(year)
(month)
In the case you need
more
space,to
(year)
(month)
please attach a separate sheet.
Total years education
16 years
Foreign Language Study (including Japanese language courses)
Foreign language
Period of study (Years)
Institution
French
2007/09－2010/06（3Years） ▲▲▲ High School
Germany
2010/09－2012/06（2Years） ◎◎◎ University
日本語能力（熟達程度を自己評価し，○でかこむこと）
Japanese Proficiency (Evaluate yourself and circle the appropriate one.)
読解力
Reading
会話力
Speaking
筆記力
Writing
理解力
Understanding
優
Excellent
優
Excellent
優
Excellent
優
Excellent
良
Good
良
Good
良
Good
良
Good
可
Fair
可
Fair
可
Fair
可
Fair
日本語学習に使用した本を記入すること。
List the Japanese language textbooks used. *if any
不可
Poor
不可
Poor
不可
Poor
不可
Poor
<Ⅵ> Other Information
Occupational experience
Name of company and / or employer
Location(Country・Region/City)
Period of employment
none
Military service etc.
□ Completed
from
Year /
/
Month
to
Year /
/
Month
□
✔
□
Yet to be done
No obligatory military service
2/2
Research Plan at Waseda University
Research Topic:
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
■ ■ ■ ■ ■ ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■.
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
【Master's Program/Research Student（Master's Program Equivalent）】
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
Prepare a summary in ~250 words in English. If you are applying to become a
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
research student (master's program equivalent) and you do not plan on taking
research instruction, you do not need to submit a research plan.
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
【Doctoral Program/Research Student（Doctoral Program Equivalent）】
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
Prepare a summary in ~250 words in English. Also submit a copy of your master's
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
thesis(in English or Japanese) or summary of your master's thesis (~2000 words in
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
English, free format).
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
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ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
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ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
ｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘｘ
WASEDA Riko
Name
Name of
Research Instruction
Name of supervisor
Application code
(three-digit)
Note:
Note:
Mathematical Logic and Set Theory
Main-supervisor
Prof. EDA Katsuya
Vice-supervisor *if any
A01
You can make copies of this form and attach a second page if you need more space.
You do not need to submit
this form if you are applying
to become a research student
(master's equivalent) and do
not wish to receive research
instruction.
State your reasons for wishing to attend graduate
school at Waseda University in 1- 2 pages.
Reason for Application
Name
WASEDA
(Family)
Riko
(First)
(Middle)
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Page 1 /
Note:
You can make copies of this form and attach a second page if you need more space.
１
Statement of Financial Resources
留学にかかる経費負担計画書
Name in full
氏名
Nationality
国籍
WASEDA Riko
United States of America
Name of Graduate or Undergraduate School
出願研究科・学部名
Graduate School of Fundamental
Science and Engineering
Department of Pure and Applied Mathematics
Desired Programs
出願課程
✔
□ Master’s Program 修士課程
□ Doctoral Program 博士後期課程
□ Research Student 科目等履修生
あなたが早稲田大学に留学する間の総費用の支出元を明記してください。
Please indicate below your source and amount of funding for your study at Waseda University.
Sources of Funds
支出元
Personal savings
Amount (Japanese yen)
金額 (単位：円)
個人貯蓄
Parents or relatives 両親または親戚
（Please specify the relation:
（関係：Father
）
）
Government / Foundation 政府またはその他財団
（The name of your sponsor:
（名称：
* Please attach a copy of scholarship award letter.
* 奨学金受給証明書のコピーを提出してください。
Others その他
（Please specify the details:
（詳細：
）
）
）
）
TOTAL:
¥
XXXXXXX
¥
XXXXXXX
¥
¥
¥
XXXXXXX
I hereby certify that all information on this statement is true and accurate and that the stated funds are available
for my educational expenses at Waseda University.
上記に示しました内容に相違ないことを誓約いたします。
志望者署名
Student’s signature
signature
日付
Feb.
Date:
Day
11,
Month
2014
Year
Waseda University