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Application Form

for Short Term Exchange Program with Scholarship(STEPs) 2012

Shibaura Institute of Technology

Please submit this application with CV and the latest transcript to

international office at home university.

Writing signature, hand-writing, on the last page after printing is necessary.

1. FULL NAME *please provide as shown in the passport

in Roman block capitals Please click here and type textsin native language, if applicable Please click here and type texts

2. NATIONALITY Please click here and type texts

4. DATE OF BIRTH

MONTH DATE YEAR

Please choose the month Please choose the date Please choose the year

5. PASSPORT INFORMATION

Number Please click here and type texts

Date of Issue (MM/DAY/YYYY) Please choose the month Please choose the date Please choose the year

Date of Expiry (MM/DAY/YYYY) Please choose the month Please choose the date Please choose the year

6. NAME OF UNIVERSITY AND DEPARTMENT *please provide your home university.

University Please click here and type texts

Department Please click here and type texts

Present Status (Ex, 4th year of Bachelor) Please click here and type texts

7. EDUCATIONAL BACKGROUND

University (Bachelor) Please click here and type texts

Major Please click here and type texts

Completion Date (MM/DAY/YYYY) Please choose the month Please choose the date Please choose the year

University (Master) Please click here and type texts

Major Please click here and type texts

3. GENDER Please choose your gender

Paste a photograph or digital

image taken within the past 6

months.

Photo

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Completion Date (MM/DAY/YYYY) Please choose the month Please choose the date Please choose the year

University (Doctoral) Please click here and type texts

Major Please click here and type texts

Completion Date (MM/DAY/YYYY) Please choose the month Please choose the date Please choose the year

8. PRESENT (MAILING)ADDRESSPlease click here and type texts

Email address Please click here and type texts

Telephone number (home) Please click here and type texts

Telephone number (mobile) Please click here and type texts

FAX number Please click here and type texts

9. TERMS Please fill out desired month to start STEPs and duration. *Range from 32 days to 62 days

Starting from Duration

1st option Please choose your desired month/year Please choose the duration

2nd option Please choose your desired month/year Please choose the duration

3rd option Please choose your desired month/year Please choose the duration

Should you have certain requests, state it here.. Please click here and type texts

10. Research field at Home university and desired research topic during STEPs at Shibaura Institute of Technology.

Please click here and type texts

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11. Desired activities at Shibaura Institute of Technology except for Lab. activity, if any

Please click here and type texts

Please answer the following items

Date Signature

Do you want to attend Japanese lessons? Please choose your answer

Are you planning to apply HBT program in SIT? Please choose your answer

Do you request to stay at DK house warabi?IfNo, you need to arrange your accommodation. Please choose your answerIfYes for , do you prefer single room?IfNo, you will share a room with other STEPs student. Please choose your answer