出願者情報 Applicant's Information *出願者の情報は選考で重要です。正しい情報を以下に入力してください。 *Applicant's information is important for the screening. Please be sure to type correct information below.
(1)
出願者氏名 Name of Applicant *パスポートに記載された氏名と同じものを入力 *Please enter the same name as the passport.
姓 FAMILY NAME
(英字大文字 IN
UPPER-CASE ROMAN ALPHABET) (e.g.: FUKUZAWA)
名 FIRST NAME
(英字大文字 IN
UPPER-CASE ROMAN ALPHABET) (e.g.:
TARO)
ミドルネーム MIDDLE NAME
(英字大文字 IN
UPPER-CASE ROMAN ALPHABET) (e.g.:
ICHIRO)
(2)
生年月日 Date of Birth
(yyyy/mm/dd)
(西暦・半角数字 In figures) (e.g.:1985/01/21)
(3)
性別 Sex
---------------
1:Male 男
2:Female 女
(4)
国籍・地域 Nationality・Region
--------------------------------------------
004:Afghanistan
008:Albania
012:Algeria
020:Andorra
024:Angola
660:Anguilla
010:Antarctica
028:Antigua and Barbuda
530:Antilles
032:Argentine
051:Armenia
533:Aruba
036:Australia
040:Austria
031:Azerbaijian
044:Bahamas
048:Bahrain
050:Bangladesh
052:Barbados
112:Belarus
056:Belgium
084:Belize
204:Benin
060:Bermuda
064:Bhutan
068:Bolivia
070:Bosnia・Herzegovina
072:Botswana
074:Bouvet
Island
076:Brazil
096:Brunei
Darussalam
100:Bulgaria
854:Burkina
faso
108:Burundi
728:C.I.S.
116:Cambodia
120:Cameroon
124:Canada
132:Cape Verde
136:Cayman
Islands
140:Central
Africa
148:Chad
152:Chile
156:China
921:China(HongKong)
996:China(Macau)
162:Christmas Island
166:Cocos
Islands
170:Colombia
174:Comoros
178:Congo
184:Cook
Islands
188:Costa Rica
191:Croatia
192:Cuba
196:Cyprus
203:Czech
180:Democratic Republic of the Congo
208:Denmark
262:Djibouti
212:Dominica
214:Dominican Republic
626:East Timor
218:Ecuador
818:Egypt
222:El Salvador
226:Equatorial Guinea
232:Eritrea
233:Estonia
231:Ethiopia
238:Faikland Islands
234:Faroe
Islands
242:Fiji
246:Finland
250:France
266:Gabon
270:Gambia
268:Georgia
276:Germany
288:Ghana
292:Gibraltar
300:Greece
304:Greenland
308:Grenada
312:Guadeloupe
316:Guam
320:Guatemala
254:Guiana
324:Guinea
624:Guinea-Bissau
328:Guyana
332:Haiti
334:Heard Island&McDonal
340:Honduras
348:Hungary
352:Iceland
882:Independent State of Samoa
356:India
360:Indonesia
364:Iran
368:Iraq
372:Ireland
376:Israel
380:Italy
384:Ivory Coast
388:Jamaica
392:Japan
400:Jordan
398:Kazakhstan
404:Kenya
296:Kiribati
414:Kuwait
417:Kyrgystan
418:Laos
428:Latvia
422:Lebanon
426:Lesotho
430:Liberia
434:Libya
438:Liechtenstein
440:Lithuania
442:Luxembourg
450:Madagascar
454:Malawi
458:Malaysia
462:Maldives
466:Mali
470:Malta
584:Marshall
Island
474:Martinique
478:Mauritania
480:Mauritius
175:Mayotte
484:Mexico
583:Micronesia
498:Moldova
492:Monaco
496:Mongolia
500:Montserrat
504:Morocco
508:Mozambique
104:Myanmar
516:Namibia
520:Nauru
524:Nepal
528:Netherlands
540:New
Caledonia
554:New Zealand
558:Nicaragua
562:Niger
566:Nigeria
570:Niue
574:Norfolk
Island
580:Northern Mariana
408:North Korea
578:Norway
512:Oman
586:Pakistan
585:Palau
275:Palestinian Territory, Occupied
591:Panama
598:Papua
New Guinea
600:Paraguay
604:Peru
608:Philippines
616:Poland
258:Polynesia
620:Portugal
630:Puerto Rico
634:Qatar
410:Republic of Korea
688:Republic of Serbia
887:Republic of Yemen
642:Romania
643:Russian Federation
646:Rwanda
654:Saint
Helena
659:Saint Kitts & Nevis
662:Saint Lucia
016:Samoa
674:San Marino
678:Sao
Tome & Principe
682:Saudi
Arabia
686:Senegal
690:Seychelles
694:Sierra
Leone
702:Singapore
705:Slobenia
703:Slovakia
090:Solomon
Island
706:Somalia
710:South
Africa
239:South Georgia
724:Spain
144:Sri Lanka
670:St. Vincent
736:Sudan
740:Suriname
748:Swaziland
752:Sweden
756:Switzerland
760:Syria
158:Taiwan
762:Tajikistan
834:Tanzania
764:Thailand
768:Togo
776:Tonga
780:Trinidad and Tobago
788:Tunisia
792:Turkey
795:Turkmenistan
798:Tuvalu
840:U.S.A
810:U.S.S.R.
800:Uganda
804:Ukraine
784:United Arab Emirates
826:United
Kingdom
923:United Kingdom(HongKong)
858:Uruguay
860:Uzbekistan
548:Vanuatu
336:Vatican City State
862:Venezuela
704:Viet Nam
850:Virgin Island(U.S.A)
092:Virgin
Island(UK)
732:Western Sahara
891:Yugoslavia
894:Zambia
716:Zimbabwe
000:Other
(5)
出願者の住所 (選考結果送付先) Applicant's Address (Address for the Screening Result to be Sent)
*選考結果は11月下旬 に送る予定です。確実に受け取ることのできる住所を登録してください。(日本国内:日本語で入力、日本国外:英字で入力)
*The screening result is scheduled to be sent
in late November . Please input the address where the result can certainly be received.
(Inside Japan: in Japanese, Outside Japan: in Roman Alphabet)
郵便番号 Postal Code
(半角英数字 In figures) (e.g.: 108-8345 / WC1B 5DN)
現住所 Present Address Address Line 1
(日本国外:半角英数字で入力 日本国内:日本語で入力)
(Outside Japan: in Roman Alphabet, Inside Japan: in Japanese) (e.g.:
三田2-15-45-123号室/ #123 5th Ave)
City
(e.g.: 港区/ New York)
State/Province/Region
(e.g.: 東京都/ NY)
国名 Country
(e.g.: 日本 / USA)
電話番号 Telephone
(半角数字 In figures/ USE NUMBERS ONLY)
(e.g.: 81354271614)
*日本国外は国番号も入力 Include the country code if outside of Japan.
(6)
出願者Eメールアドレス Applicant's E-mail address
(e.g.: jlpinquiry@info.keio.ac.jp )
(7)
現在の在留資格 Present Status of Residence
(国内出願者のみ only if you currently reside in Japan)
(e.g.
留学Student/文化活動Cultural Activities/配偶者Spouse)
(8)
学歴 Educational Background
出身学校名 Name of Institution
ENGLISH NAME (半角英字 In Roman Alphabet) (e.g. London University)
* 中国、台湾、韓国、日本の大学は、漢字で入力。 (e.g. 北京大学)* Chinese, Taiwanese, Korean or Japanese Institutions must be in Chinese characters. (e.g. 北京大学)
在籍状況 Status
--------------------------------------------------------------------------
学部在学中:Currently Enrolled in Undergraduate Course
学部卒業:Graduated from Undergraduate Course (Bachelor's Degree)
修士課程在学中:Currently Enrolled in Master Course
修士課程修了:Completed Master Course (Masters Degree)
博士課程在学中:Currently Enrolled in Doctor Course
博士課程修了:Completed Doctor Course (Doctoral Degree)
高校卒業:Graduated from Highschool
短期大学在学中:Currently Enrolled in Associate Degree Course
短期大学卒業:Completed Associate Course (Associate Degree)
退学:withdrawal
休学:absent from school
学校所在国 Country of the
Institution
--------------------------------------------
004:Afghanistan
008:Albania
012:Algeria
020:Andorra
024:Angola
660:Anguilla
010:Antarctica
028:Antigua and Barbuda
530:Antilles
032:Argentine
051:Armenia
533:Aruba
036:Australia
040:Austria
031:Azerbaijian
044:Bahamas
048:Bahrain
050:Bangladesh
052:Barbados
112:Belarus
056:Belgium
084:Belize
204:Benin
060:Bermuda
064:Bhutan
068:Bolivia
070:Bosnia・Herzegovina
072:Botswana
074:Bouvet
Island
076:Brazil
096:Brunei
Darussalam
100:Bulgaria
854:Burkina
faso
108:Burundi
728:C.I.S.
116:Cambodia
120:Cameroon
124:Canada
132:Cape Verde
136:Cayman
Islands
140:Central
Africa
148:Chad
152:Chile
156:China
921:China(HongKong)
996:China(Macau)
162:Christmas Island
166:Cocos
Islands
170:Colombia
174:Comoros
178:Congo
184:Cook
Islands
188:Costa Rica
191:Croatia
192:Cuba
196:Cyprus
203:Czech
180:Democratic Republic of the Congo
208:Denmark
262:Djibouti
212:Dominica
214:Dominican Republic
626:East Timor
218:Ecuador
818:Egypt
222:El Salvador
226:Equatorial Guinea
232:Eritrea
233:Estonia
231:Ethiopia
238:Faikland Islands
234:Faroe
Islands
242:Fiji
246:Finland
250:France
266:Gabon
270:Gambia
268:Georgia
276:Germany
288:Ghana
292:Gibraltar
300:Greece
304:Greenland
308:Grenada
312:Guadeloupe
316:Guam
320:Guatemala
254:Guiana
324:Guinea
624:Guinea-Bissau
328:Guyana
332:Haiti
334:Heard Island&McDonal
340:Honduras
348:Hungary
352:Iceland
882:Independent State of Samoa
356:India
360:Indonesia
364:Iran
368:Iraq
372:Ireland
376:Israel
380:Italy
384:Ivory Coast
388:Jamaica
392:Japan
400:Jordan
398:Kazakhstan
404:Kenya
296:Kiribati
414:Kuwait
417:Kyrgystan
418:Laos
428:Latvia
422:Lebanon
426:Lesotho
430:Liberia
434:Libya
438:Liechtenstein
440:Lithuania
442:Luxembourg
450:Madagascar
454:Malawi
458:Malaysia
462:Maldives
466:Mali
470:Malta
584:Marshall
Island
474:Martinique
478:Mauritania
480:Mauritius
175:Mayotte
484:Mexico
583:Micronesia
498:Moldova
492:Monaco
496:Mongolia
500:Montserrat
504:Morocco
508:Mozambique
104:Myanmar
516:Namibia
520:Nauru
524:Nepal
528:Netherlands
540:New
Caledonia
554:New Zealand
558:Nicaragua
562:Niger
566:Nigeria
570:Niue
574:Norfolk
Island
580:Northern Mariana
408:North Korea
578:Norway
512:Oman
586:Pakistan
585:Palau
275:Palestinian Territory, Occupied
591:Panama
598:Papua
New Guinea
600:Paraguay
604:Peru
608:Philippines
616:Poland
258:Polynesia
620:Portugal
630:Puerto Rico
634:Qatar
410:Republic of Korea
688:Republic of Serbia
887:Republic of Yemen
642:Romania
643:Russian Federation
646:Rwanda
654:Saint
Helena
659:Saint Kitts & Nevis
662:Saint Lucia
016:Samoa
674:San Marino
678:Sao
Tome & Principe
682:Saudi
Arabia
686:Senegal
690:Seychelles
694:Sierra
Leone
702:Singapore
705:Slobenia
703:Slovakia
090:Solomon
Island
706:Somalia
710:South
Africa
239:South Georgia
724:Spain
144:Sri Lanka
670:St. Vincent
736:Sudan
740:Suriname
748:Swaziland
752:Sweden
756:Switzerland
760:Syria
158:Taiwan
762:Tajikistan
834:Tanzania
764:Thailand
768:Togo
776:Tonga
780:Trinidad and Tobago
788:Tunisia
792:Turkey
795:Turkmenistan
798:Tuvalu
840:U.S.A
810:U.S.S.R.
800:Uganda
804:Ukraine
784:United Arab Emirates
826:United
Kingdom
923:United Kingdom(HongKong)
858:Uruguay
860:Uzbekistan
548:Vanuatu
336:Vatican City State
862:Venezuela
704:Viet Nam
850:Virgin Island(U.S.A)
092:Virgin
Island(UK)
732:Western Sahara
891:Yugoslavia
894:Zambia
716:Zimbabwe
000:Other
既に取得した学位 Degrees already awarded (if any)
* 最終学歴が高等学校の場合は、何も選択しないでください。 * If your latest graduate institution is
"high-school," please do not choose anything below.
----------------------------
Associate
Bachelor
Master
Ph.D.
* あなたが既に取得した学位の詳細を、学位証明書に記載してあるとおり以下に入力してください。 取得予定学位は書かないでください。 * Please fill in more details of your awarded degrees
that might be in your official
certificates. DO NOT write degrees that are to be
awarded in the future.
(半角英字 In Roman Alphabet)
*In short names (Associate: A./Bachelor: B./Master: M.)
(e.g. B. of Arts in Literature)
B.
下記のアンケート回答にご協力ください。回答が合否を左右することはありません。 Please answer the questions below. This section will not affect the screening results.
1. 慶應義塾大学別科・日本語研修課程をどのように知りましたか?(複数回答可)
How did you find Keio JLP program? (Check all that apply)
慶應義塾大学のウェブサイトから
Website
of Keio University
指導教員から Academic Advisor
友人・家族・知人から Friends, family or acquaintances
慶應義塾大学の関係者から Person related to Keio
留学フェア Study Abroad Information Fairs
参加した留学フェアの場所・日時 Place and date of the Information Fairs
その他 Other
2. 1.で慶應義塾大学の関係者からを選択した方は回答してください。それはどんな方ですか?(1つ選択) (If you answer "Person related to Keio" in item 1, what kind of a person is he or she? (Check ONE that apply)
別科の在学生または卒業生
Student enrolled in or graduated from the JLP
学部/大学院の在学生または卒業生
Student enrolled in
or graduated from Keio undergraduate/graduate school
三田会(慶應義塾大学の同窓会組織)の会員 Member of Mita-kai (Keio alumni association)
その他
Other
3. 慶應義塾大学別科・日本語研修課程に出願を決めた理由は何ですか?(複数回答可) Why did you choose Keio JLP? (Check all that apply)
カリキュラム
Curriculum
学費
Tuition fees
知名度 Publicity
教わりたい先生がいるから
Instructors
指導教員から勧められたから
Recommended by Academic Advisor
学校の立地
Location
その他
Other
4. 他大学を併願していますか?もし併願している場合、どのような課程に併願していますか? Are you applying for other programs along with Keio JLP? If YES, what kind of program are you applying for?
別科
Japanese Language Program
学部 Undergraduate Program
大学院
Graduate Program
その他
Other
併願してない
No other application
5 別科・日本語研修課程修了後に希望する進路(1つ選択) What is your plan after completion of the JLP?
(Check ONE that apply)
日本で大学(学部)に進学 Admission to an undergraduate program in Japan
日本で大学院(修士課程)に進学 Admission to Master's program in Japan
日本で大学院(博士課程)に進学 Admission to Doctorial program in Japan
母国または他国で進学
Study in home country or other country
日本で就職
Work in Japan
母国または他国で就職
Work in home country or other country
未定 Undetermined
その他
Other