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Language Ability (Please circle the level which best describes you.)○

/

○

Other ○

Other ○

春学期 秋学期１．受付 １．受付

２．登録 ２．登録

３．評価 ３．評価評 評確 確新 新

*Instruction for inputting into Excel:

Input into green spaces. Select from pull-down menu if space has one.

Beige spaces will have information automatically inputted. Do not input yourself.

Degree Type Master's

Faculty of

Graduate School of

N/A

Major: Academic Advisor:XXX Economics Keio　〇〇

Year

319 /

Reason:20

3/21 Leave of absence due to ××

T0EFL iBT 100―Good

―Very good

090**** **** -

―Good ―Fair

ＴＥＬ

Department of N/A Year

** XX Road, XX District. Qingdao, Shandong Sheng 2660**, China

****

****

**** - -

2ndEconomics

Ｂ②　受給希望調査書作文

No.3

Sex(Male/Female)

31

Middle Name

3

1 24

Ｃ②　（指導教員）奨学生評価票

Ｂ③　成績表コピー（大学院新入生は『評価方法』必須）Ｂ④　本人のアルバイトに関する書類Ｂ⑤　家族・援助者の所得に関する書類Ｃ①　外国人登録証明書コピー

No.4Ｂ①　学習計画書、研究計画書

Ａ　奨学金受給希望調査書

Very good

Japanese Language Proficiency Test N1 Date obtained (yyyy/mm)

Japanese

No.2

春 秋

Father

―Fair

―Good ―Fair

Native

Native ―Very good

―Very good

―Poor―Fair

**

ContactAddress in

HomeCountry

Name Wang △△

****-

Relationship

ＴＥＬUncleRelationship

20

***@a8.keio.jp

***@adst.keio.ac.jp

EmergencyContact

(in Japan)

270

Name

-

Zhang　□□

*** Chiba-shi, Chiba-ken〒

CurrentAddress

-108〒

E-mail address(１)：

8345

-

E-mail address(２)：

Tel (Home) 03 -

/

208 xx Building, Mita, Minato-ku, Tokyo

-

/

20

20

Enrollment on Present Program(yyyy/mm)

Repeat/Leave of absence

2020 20 / 4 -

/

ＮＯ．1Scholarship Applicant Registration Form

/

Male

ChineseNationality

＊Any false declaration of information will result in the rejection of the application for all scholarships.

PHOTO

Photocopies Accepted

Student Period of Stay

2021 Spring

20 21 /Status of Residence

Student ID No.

Family NameDate of Birth(yyyy/mm/dd)

〇〇

First Name

Qualifications

2021/3/30

WangName in full

(in English, incapital letters)

19

―Poor

97 / Age1

Level

Korean

80000000

/

//

20 4 20 22

Reason:

**-****－****

Mobile

Reason:

****

-

Completion/Expected Completion of PresentProgram (yyyy/mm)

Ｃ③　成績計算書【大学院新入生のみ】

―Good

No.1

Qualifications

―Poor

―Poor

2018 12

Native

English

Chinese Qualifications

――――――――――――――　国セ使用欄 For Official Use Only　――――――――――――――

sampl

Submission Date

Please write the expiration date indicated on your Residence Card.

Make sure you complete this section if you have repeated some part of your course, or if you taken a leave of absence.

sample

Please provide the contact information of an acquaintance in Japan with whom you keep in daily touch, such as a friend on

Indication of language ability:

Very good: You have no difficulty in understanding lectures or research seminars in this language.

Good: You can read and write in this language.

Fair: You can communicate in daily situations in this language.

Please do not write in this space.

＜Monthly Income＞（Fill out average monthly income from April 2020 to March 2021）

*Don't include tuition assistance from your parents or guarantor in the allowance above.*For scholarship, please fill in what determined to receive. *Please note that students who receive an allowance of 90,000 yen or more are not eligible for the Honors Scholarship (JASSO).

Give specific information about your income in the form below.

*Fill out the weekly average of hours worked during semester.

Lender (Relationship)

* Please write your total income amount in the space for Part-Time Job (B) if you have three part-time jobs or more.

Monthly Expenses Please insert the average amounts of your monthly expenses.Type of □ Keio Accommodation □ Company Accommodation for International StudentsAccommodation ☑ Private Apartment □

□ Home Stay □ Living with parents, family or guarantor (free of rent)Please check the □applicable box ☑ □ Other ( ）

□ No. □ Yes. □ Spouse □ ） □ ）

☑ 1 ） □ ）

About Payment of Academic Fees at Keio University (Tuition & Other Fees)20 21 as of 2021/ 0 / 0 (mm/dd)

☑ Family□ Financial Supporter

□☑ Self□ ☑ Part-Time Job □ ）□ （ ）□ ☑ / 8 / 30 (yyyy/mm/dd)

☑ Family□ Financial Supporter

□□ Self

□ ☑ Part-Time Job

□ ）

□ （ ）

3. Loan

Detail

4. Scholarship

¥0

Total

Student Accommodation (for both Japanese and International Students)

Father

Monthly Rent

XX store-XX ten

Total Amount

hrs/week

12 hrs/week*Working more than 28 hours a week is prohibited

Type of Work

¥32,000

Monthly Average ¥0

Details

Accommodation for International Students (except Keio Accom.)

Name of Accommodation/Apartment XX Building

Part-Time Job (C) XX Chinese language schoolEmployer

Zhang □□1. Allowance (A)

3. Loan

Part-Time Job (D) Type of Work

Allowance (B)Type of Work

¥0

RelationshipFrom

¥30,000

¥128,000¥8,000¥0

Wang △△From

ＮＯ．２

Student ID No.

Scholarship Applicant Registration Form

80000000

2. Part-Time Job(Wage Income)

(C)

5. OtherIncome

6. SavingDeposit

Total Amount ofMonthly Income

1. Allowance(A)

1. Allowance(B)

Name infull:

Wang 〇〇 2021/3/30Date

2021 Spring

¥80,000 ¥10,000 ¥30,000 ¥0

2. Part-Time Job(Wage Income)

(D)

(A)＋(B) ¥10,000 (C)＋(D)

hrs/weekEmployer

Relationship

9Uncle

(unit：YEN）

hrs/weekEmployer Part-time worker2. Part-Time Job (A)

¥64,000 Common-area fee/Management fee

＊Please include in "2. Part-Time Job" all income from work such as language instruction, translation, and the salary for any research assistance.

¥12,000

　 Submit proof of earnings for all part-time work (e.g., copy of tax withholding record, employment agreement or other confirmation of employment).

Teacher

5. Other Income

3

House Size （e.g. 8-tatami room, kitchen, bathroom） 8-tatami room, kitchen, bathroomAmount of rent you pay

Detail: Child （ Brother/Sister（

Friend （ Other （Reason if you do not pay rent

2. Food Monthly Average ¥18,000

1. Housing Expenses

Housemate(s)

¥38,000

3. Books/Stationery Monthly Average ¥15,0004. Transportation Monthly Average ¥5,000 Please include payment for student commuter pass. (Monthly average)5. Daily Expenses Monthly Average ¥10,000 Reason Seminar-related activities

6. Allowance to Family Recipient

Cell-phone/Internet8. Savings Monthly Average ¥10,000 Total Savings ¥400,000 Reason

Payer of Paid AcademicFees(Check all that apply☑) Scholarship which covers full tuition & other fees

Paid Academic Fees I have already paid for academic year

If you paid part of theamount, how did youprocure the money?

SavingsLoan （from whom：Other

Savings

Loan

Payment for 2021Academic Fees

I have already paid I will pay by 2021Amount of 2021 Academic Fees ¥800,000

（From whom：

Doctoral course

7. Other Expenses

Other

Payer ofAcademic Fees due tobe paid from now(Check all that apply☑)

Scholarship which covers full tuition & other fees

If you paid part of theamount, how did youprocure the money?

(unit：YEN）*New students enrolling in Spring Semester 2021 should fill out their expected monthly income from April 2021.

Total Total ¥128,000

SemesterSpring

Monthly Average

Total amount of monthly income and monthly expense are matched.

Hours from part-time work during holidays or full-time jobs before enrollment are not required.

New students enrolling in April 2021 should write expected monthly income from April 2021.Students who have already been studying at Keio before April 2021 should write their average monthly income. Even if you were working full time, please write this in "Part-Time Job". All amounts must be given in Japanese yen.

If you live with your family in Japan, fill out the income and expenses that concern you only. The amount of financial support you receive for living costs, etc. should be included in "1.

Information about the tuition you already paid for and information about the tuition you will pay for from now must be described separately.

Fill out expeted monthly income from April 2021, if you are a new student (enrolled in Spring 2021) of Keio University.

The amount of rent you are responsible for paying each month, including any common area and management fees.

＜Financial Support＞ ＊Please attach documents to certify the latest income for your parents (or spouse) and financial supporters.

1. Family Member

2. Financial Sponsor (Other than Family)

↑ *Please circle the financial supporter you gave in your application for admission.*If one of the conditions fullfilled for separation, please fill in the blank.*Include all periods since high school education and any employment, training, housekeeping, etc.

* Be careful not to leave any period of time unaccounted for.

Plans after Graduation *Check all that apply☑□ Enter Graduate School (M.A.)

☑ Enter Graduate School (Ph.D.)

□

□

Health Condition *Check the box. ☑ You must have a medical check-up at the Health Center on Mita Campus.

□ ☑

If "Yes," please explain:

Additional Notes & Achievements: Space to include details of awards, punishments, qualifications, strengths, etc.

-

-

(yyyy/mm)

2019

4

-

-(yyyy/mm)

3

Name of University

/

(yyyy/mm)

4 (yyyy/mm)

Name of University

Country/Region

2015 /

/ - (yyyy/mm)(yyyy/mm) /

(yyyy/mm)

/

/ / -

2014

2015

2019

2020

4

2021

/

/

4

/

(yyyy/mm) -/

/

(yyyy/mm)

(yyyy/mm)

\

\

3

0

\ 5,000,000

1,200,000

1,500,000

Hiyoshi Inc. 5,000,000 yen

80,000 yuan

\

\

0

(yyyy/mm)

Zhang □□

-10

2014 / (yyyy/mm)6 Name of UpperSecondary/High School

○ Uncle 50

＜Personal History＞

Japanese Japan, XX, Chiba

Qingdao, Shandong, China XX Company

2021 Spring

Name in full: Wang 〇〇

Wang ●● Olderbrother

35 Chinese

Chinese

ＮＯ．3

Student ID No.

Scholarship Applicant Registration Form

Date 2021/3/3080000000

Spouse

Qingdao, Shandong, China UnemployedLi ☆☆ Mother 54

Chinese Qingdao, Shandong, China China XX Bank 100,000 yuanWang △△ ○ Father 54

Current Address（Country/Region/C

ity）

Place ofEmployment/

School

2020 AnnualIncome(in local

currency)

2020 AnnualIncome(in yen)

Name in fullFinancialSupporter

NationalityRelation-

shipAge

Japan/Tokyo

Japan/Tokyo

\

\

\

Graduated or passed high schoolequivalence test

Country/Region

China/ShandongCountry/Re

gionQingdao High School

/ (yyyy/mm)3

(yyyy/mm) Completed X Japanese Language School preparatory class

Graduated Keio University: Economics

since I was in my first year of college.

I want to introduce what I have learned about Japan to people in my country when I return.

/

/

/ (yyyy/mm)

/ (yyyy/mm) 2021

- (yyyy/mm)/

(yyyy/mm)

(yyyy/mm)

In November 2014, I won the Principal Award in the Speech Contest at XX Japanese Language School.

I have been interested in Japanese culture and have been learning Japanese drums called Wadaiko

Enrolled Keio Graduate School of Economics: Master's Program

Leave of absence due to ××

Country/Region

Country/Region

Country/Region

Country/Region

Currently studying at Keio Graduate School of Economics: Master's Program

Country/Region

Country/Region

Japan/Tokyo

××・××

Country/Region

Japan/Tokyo

(yyyy/mm)

Yes No

/

Other

Do you have any health problems?

(yyyy/mm)

□

Japan/TokyoCountry/RegionKeio Graduate School of Economics: Doctoral Program

Work in Japan Industry and company where you want to work

-

Return to home country　＊Write your plans in detail in the space below, if you have already decided.

/

Country/Region

Country/Region

You must submit documents to certify the latest income stated in these spaces.For the details, please refer to "Documents Required for Scholarship Application Registration for Sprng 2021 ".

Make sure to include details of any leaves of absence, study abroad experience, or repeated years while at university.

History of Scholarships Rreceived at Keio University

or the Yamaoka Scholarship.) You do not need to list scholarships which you are currently applying for. ＊Please refrect information on "Name of Scholarship (receiving and going to receive, including a scholarship from outside of Japan)"to the "Monthly Income" at the sheet No.2.＊If you receive a stipend annually, fill in the amount that is divided by 12.

For married students: Scholarships your spouse currently receives.

Future Scholarships you want to apply for (For reference only: Applications for each scholarship must be made separately.)（Please check the box. ☑）

☑□

☑

□

Please explain your financial situation and clarify your scholarship need.

×××××××××××××××××××××××××××××××××××××××××××××××××

×××××××××××××××××××××××××××××××××××××××××××××××××

×××××××××××××××××××××××××××××××××××××××××××××××××

×××××××××××××××××××××××××××××××××××××××××××××××××

I asked

(MM/DD) .

(MM/DD) .

PledgeTo: Director of the International Center,

Keio University

I, the undersigned, hereby pledge the following:1) The information provided herein is correct and complete.2) If any changes occur in the information stated above, I will contact the International Center as soon as possible.3) If I break either of 1) or 2) above, I will accept any measures taken by Keio University.4) I agree with the Policy for Handling Personal Information stated below.

/ 3 / 30

to fill in the evaluation on 03/01

Your academic advisor will submit the evaluation through the designated form by 03/28

Prof. Futoshi Ishii*Students who newly entered Keio in Spring Semester 2021 don’t need to submit an evaluation.

2019 -

Note: If the evaluation is not submitted to the office in charge, it may bring disadvantage for scholarship applications.

-

(Name of your academic advisor) in the Faculty/Graduate School of

Wang 〇〇 Student ID No. 80000000

/

/

/

/

Extention

/

- /

/

-

-

-

Policy for Handling Personal Information: The personal information stated in and attached to this Scholarship Initial RegistrationForm will be used for the purposes of scholarships screening, and for the issuance of scholarship benefits. Within the fulfilment ofthese purposes, your information may be provided as necessary to the Ministry of Education, Culture, Sports, Science andTechnology; JASSO; financial institutions; and various foundations. It will not be used for any other purposes.

（Signature） 王　○○

(yyyy/mm/dd)2021

Keio University Scholarship or Keio Graduate School Scholarship

Other

DesiredConditions

Economics

Possibility of exchange activitiesScholarships Provided by PrivateFoundations/Local Governments

Desired MonthlyAmount

¥70,000

Honors Scholarship

Monthly - /

2021 Spring

2020

Monthly/Annually

Monthly

Amount of Stipend

2021/3/30

ＮＯ．４Scholarship Applicant Registration Form

×

Extention

/ -

-

Date

/

-

/ - /

¥48,000

/

/

Name infull:

/

/

MonthlyName of Scholarship

/

/

MonthlyN/A

Monthly

//

Amount of Stipend

/

/

-

-

/

Period(yyyy/mm - yyyy/mm)

/

/

/

*Please list all scholarships you have received sat Keio (i.e., Honors Scholarship, Keio University Scholarship, Keio Graduate School Scholarship,

Name of Previous ScholarshipPeriod

(yyyy/mm - yyyy/mm) Honors Scholarship 4 3

Name of Scholarship (which you are receiving or which you are going to receive, including a scholarship from outside of Japan）

MonthlyN/A

Monthly

You must write your signature by hand. Digital sign is also

No.1No.2No.3No.4