Mẫu 4 - APPLICATION FORM

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Mẫu 4

<APPLICATION FORM>

MHI SCHOLARSHIP PROGRAM 2016

　 　 　 Instructions

1 ． Type application, if possible, or write neatly by hand in block letters

2 ． Use Arabic numerals

3 ． Write years in the Anno Domini system

4 ． Write proper nouns in full without abbreviation

※ Personal data entered in this application will only be used for scholarship selection purposes, and contact information such as email addresses will only be used to create academic networks after the student returns home and by Ministry of Education and Training of the Socialist Republic of Vietnam (“MOET”) and Mitsubishi Heavy Industries, Ltd (“MHI”) to send out information when needed

1-1) Name in full, in your native language

． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． , ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ．

(Family name/Surname) ． (Given name) ． ． ．

(Middle name) 1-2) In Roman capital letters ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． , ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． (Family name/Surname) ． (Given name) ． ． ．

(Middle name) ． *Please write your name exactly as it appears in your passport 2-1) Nationality ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． 2-2) Possession of Japanese nationality 　 □ Yes, I have ． ． ． ． □ No, I don’t have 3) Sex 　 ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． □ Male ． ． ． □ Female 4) Marital Status □Single ． ． ． ． □ Married 5) Date of birth and Age as of April 1,2016 ． ． ． ． ． ． 19 　 　 　

． ． ． ． ． (Year) ． ． ． ． ． ． (Month) ． ． ． ． ． (Day)

(Age) 6) Present address, telephone / facsimile number, and E-mail address ． ． ． Present address :

． ． ． ． ．

． ． ． Telephone/Facsimile number: ． ．

． ． ． E-mail address:

． ． ． ． ．

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Paste your photograph

or digital image taken within the past 6 months Write your name and nationality in block letters on the back

of the photo

．photo size:4.5 cm x 3.5 cm．

． ． ． ． * If possible, provide an e-mail address that can be used continuously before, during and after your stay in Japan

7) Preferred field of study in Japan

． First choice: ． ． ． ．

． ． ． ． ．

． ． Second choice: ．

． ． ． ． ．

． ． Third choice: ． ．

8) Present status with name of school attending: ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． in ． ． ． ． ． ． ． ． year/ will graduate in ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． ． Name of school ． (Grade) ． ． ． ． ． (Year) ． ． ． (Month) 9) Field of study you majored in at high school ． ． ． ． ．

2

10) Academic background:

Name and Address of School

Year and Month

of Entrance and

Duration of Attendances

Diploma or Degree awarded, Major Subject, Skipped years/levels Elementary

Education

Elementary

School

Name

Location

From

To

． years

and months

Secondary

Education

Lower Secondary

School

Name

Location

From

To

． years and

．

． months

Upper Secondary

School

Name

Location

From

To

． years and months

*-1

Higher Education

Undergraduate

Level

Name

Location

From

To

． years and

． months

Total of the years schooling mentioned

above

As of April 1, 2016

． ． ． ． ． ． ． ． years and

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

3

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 house 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 studied 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 stipulate that the information is on a separate page.

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11) Reasons for wishing to study in Japan

12) Reasons for choosing the fields of study entered in section 7

Specify reasons for each field of study entered in section 7

Also, ensure that the fields of study in this section are the same as the fields of study entered in section 5

Field of study and reasons

． ． ． First choice:

． ． Second choice:

． ． Third choice:

13) What academic field would you like to study in Japan?

14) What kind of impression do you have of Japan?

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15) What kind of occupation/profession would you like to enter after studying in Japan?

16) What kind of impression do you have of MHI?

17) How do you want to contribute to development of Vietnamese machinery industry in the future?

18) Language proficiency:

． Evaluate your ability as “Excellent", “Good", or “Poor" in each blank space

Japanese English Others ( ． )

19) Japanese language background, if any.

i) Name and address of institution

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． ． ． ． ． ． ． Name: ． ．

． ． ． ． ． ． ． Address: ． ． ii) Period of study ．

． ． ． ． From ． ． ． ． ． ． ．

to ． ． ． ． ． ． ． ． ． ． ． ．

． ． ． ． ． ． ． ． ． ． Year Month ． ． ． ． ． ． Year Month

． Duration

7

20) Visits or stays in Japan, if any List from your most recent visits.

From:

To:

From:

To:

21) 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:

I understand and accept all of the terms and conditions stated in the “Announcement of MHI Scholarship Program” for 2016, and hereby apply for this scholarship Date of application:

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Applicant's signature:

Applicant's name (in Roman block letters capitals):

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