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Tokyo Institute of Technology

Global Scientists and Engineers Program (GSEP)


April 2019 Application Form
- Please type the answers or write clearly in BLOCK CAPITAL LETTERS and tick boxes
where applicable.
- Numbers should be written in Arabic numerals.
- Years should be written using the A.D. (19YY, 20YY) system.
- Acronyms and abbreviations should be spelled-out the first time.
- Personal data in this application will only be used for admissions purposes.

1. Name in full

(a). In your native language

, ,
(Family Name) (Given Name) (Middle Name)

(b). In capital Roman letters

, ,
(Family Name) (Given Name) (Middle Name)

※Please write your name exactly as it appears on your passport.

2. Nationality

(a). Japanese nationality


 Yes  No

(b). Others

Paste a photograph of
yourself taken within the
3. Sex
past 6 months. Write your
 Male  Female name and nationality in
block letters on the back
4. Marital Status of the photo.

 Single  Married (photo size:4.5 cm x 3.5 cm)

5. Date of Birth

Year Month Day Age (as of April 1, 2019)

6. Present address, telephone / facsimile number, and e-mail address


Present address:
Telephone/Facsimile number:
E-mail address:
* If possible, provide an e-mail address that can be used continuously before, during and after
your stay in Japan.
7. Current status with name of the school you are attending or your employer:
 a) Student  b) Employed  c) Other

a) Student : Name of school


in year/ will graduate in Year Month
b) Employment: Name of employer
c) Other:

8. Field of study you majored in high school or university: _______________________

9. Academic Background:

Year and Month Diploma or Degree


Name and Address of School Duration of
of Entrance and Awarded, Major Subject,
Attendance
Completion Skipped Years/Levels

Elementary Education Name From


years

Location and
Elementary School To
months

Secondary Education Name From


years

Location and
Lower Secondary School To
months

*-1
Name From
years
Upper Secondary School Location and
To
months

Higher Education Name From


years
Location and
Undergraduate Level To
months

years
Total number of years studied mentioned above
and
As of April 1, 2019
months

Notes: 1.Exclude kindergarten education and nursery school education.


2.Preparatory education for university admission is included in secondary education.
3.If the applicant has passed the university entrance qualification examinations, indicate this in the column with “*-1.”
4.Any school years or levels skipped should be indicated in the fourth column (Diploma or Degree Awarded, Major Subject, Skipped
Years/Levels). (Example: Graduated high school in 2 years.)
5.If you attended multiple schools at the same level of education due to moving of residence or readmission to university, then write the schools
in the same column and include the number of years of study and current status for each school.
6.Calculate and write the total number of years of education based on duration as a student. (including extended leave such as summer
vacation)
7.You may use a separate piece of paper if the above space is insufficient. In such a case, please state clearly that additional information is
written on a separate page.
10. Language proficiency:
Evaluate your ability as "Excellent", "Good", or "Poor" in each blank space.

Reading Writing Speaking

Japanese

English

Others ( )

11. Previous visits or stays in Japan. List from your most recent visit.
Date Purpose

From

To
From

To

12. Person to be notified in applicant's home country, in case of emergency


i) Name in full:
ii) Address, telephone/facsimile number, and e-mail address:
Present Address
Telephone/Facsimile number
E-mail address
iii) Occupation:
iv) Relationship with the applicant:
v) Name(s) of family member(s):
Father Occupation Nationality
Mother Occupation Nationality

13. If you know a Tokyo Tech faculty or alumni association member, please provide his/her
contact information. (This is not mandatory, but he/she may be consulted and his/her
comments taken into account during the application screening.)

Name:

Relationship:

Address:

Tel:

Fax:

E-mail:
14. Essays
a) Why do you wish to enroll in this degree program at Tokyo Institute of Technology?
How will completing this degree program contribute to achieving your career objectives?
(max. 500 words)
b) Please tell us about yourself, including the following:

▪ What are your academic strengths and current goals?


▪ What kind of activities have you initiated or taken part in as a student?
▪ What leadership experience do you have?
▪ Comment on your knowledge regarding Japanese culture and the language.
▪ List any awards or certifications that you have received in sports or academia.
(max. 500 words)

Date:

(yyyy/mm/dd)

Signature:
[Questionnaire] Please type all your answers.
Admission results will be sent by post in mid-November 2019 Please write the postal address,
telephone and facsimile numbers, and email address through which you can be reached at this time.

Address:

Postal code: Country:


Phone number:
Fax number:
Email address:

Applicants who intend to apply for the Japanese Government (MEXT) Scholarship are requested to
provide the following information:

 Japanese embassy or consulate nearest to your residence in your home country:

MEXT Scholarship students are required to embassy or consulate in their country of nationality.

 International airport in your country of nationality that you will use to travel to Japan:

Name of Airport:
Location (City/Province/Country) of Airport:

In accordance with MEXT regulations, MEXT Scholarship students will be provided an economy
class air ticket from the international airport closest to their place of residence in their country of
nationality to Narita or Haneda International Airport.

Please provide your (expected) postal address, telephone number, and email address in your home
country as of April, 2019.

 Unchanged from November 2018


 Expected residence as of April 2019

Address:

Phone number:
Email:

If your address changes after submission, please inform the Tokyo Institute of Technology
Admissions Division.

E-mail: nyu.gak@jim.titech.ac.jp
Tokyo Institute of Technology
Global Scientists and Engineers Program (GSEP) 2019
Application Check Sheet
Name in Full (FAMILY NAME, First Name) Nationality

1. Select the eligibility and conditions that correspond to your application to GSEP.

 (a) I wish to enroll in this program as a privately-funded international student. I currently do not
live in Japan.
 (b) I wish to enroll in this program as a privately-funded international student. I currently live in
Japan.
 (c) I wish to enroll in this program as a privately-funded international student. However, I will
register as a MEXT scholarship student if I awarded the MEXT scholarship.

2. This section applies for those who selected 1(a) or 1(b).


Applicants who did not qualify for the Japanese Government (MEXT) Scholarship may apply for the
Monbukagakusho Honors Scholarship for Privately Financed International Students offered by
the Japan Student Services Organization (JASSO).

Do you wish to apply for the Monbukagakusho Honors Scholarship for Privately Financed
International Students?
 Yes
 No

Please note that those who are already recipients of a scholarship are not eligible to apply for the
JASSO scholarship. The scholarship will provide a monthly stipend of ¥48,000 (JPY), and is subject
to change in accordance with JASSO directives. The scholarship will be provided from April 2019 to
March 2020 (12 months). Please note that recipients of this scholarship are still required to pay
admission and the tuition fees.
4. [Application Documents]

Please check the following boxes()and submit these application documents by the
deadline.

 (1) GSEP Application Form (Attached form: original, no photocopies)

 (2) Questionnaire (Attached form, should be type-written)

 (3) Check Sheet (Attached form, this form)

(4) Passport photocopy (photocopy of the page(s) that show the applicant’s name, nationality,
date of birth and photo)
*Only applicants who currently reside in Japan are required to submit the Certificate of
 Residence (juminhyo) or a photocopy of both sides of their Residence Card (zairyu card)
to prove their status of residence and authorized period of stay. Only original copies of
the Certificate of Residence will be accepted.

 (5) Official Academic Transcripts (Original or certified true copy)

(6) Certificate of Graduation or Expected Graduation (Original or certified copy)


*If the applicant’s high school does not issue graduation certificates, please check the
 following box.
 I have submitted other notarized documents that authenticate my graduation and/or
expected graduation.

(7) TOEFL, TOEIC or IELTS test scores


(No photocopies -- only original documents will be accepted. TOEFL-ITP, TOEIC-IP will
not be accepted.)
If you have not requested the official score sheets to be directly delivered to the
Admissions Division of Tokyo Tech by the ETS/British Council, please leave the boxes
unchecked.
  TOEFL (Test Date: . . )
 IELTS (Test Date: . . )

Applicants who have requested an exemption from the submission of English test scores,
please check following box.
I have requested for an exemption from submitting English test scores.
(8) The "Payment Verification" page (printed copy)
Please print out the "Payment Verification" page that appeared on the screen at the end
 of the payment process and include the sheet in your application package.
Tokyo Tech will NOT accept any payments made by cash or check.

[Individual Assessment]
 I have applied for the Individual Assessment of Admission Eligibility.