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ASEAN in Todays World 2012 Application Form

Please complete in block letters, Arabic numerals, years in Anno Domini system, proper nouns in full and not abbreviated.

HOME INSTITUTE: COUNTRY: PERSONAL DATA:

Name in full
(in Roman block family name / first name / middle name

capitals)

Date of Birth
yyyy / mm / dd

Age: Married?

Se x Yes / No

M/F

Nationality (Citizenship) Student ID

(Students of Kyushu University and Fukuoka Womens University only) Present address and telephone number, facsimile number or e-mail address

Address Post-code Telephone E-mail

Please fill in your most active Email address. The office will send you important notice by Email

Country Fax

Emergency contact in your home country in case of emergency Name in full Relationshi p Address Post-code Telephone E-mail
LANGUAGE PROFICIENCY (except for your mother tongue) En g lish None / Beginner / Intermediate / Post-intermediate / fluent
Jap a ne se None / Beginner / Intermediate / Post-intermediate / fluent

Country Fax

Exam. Score

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Th a i Fil ip ino S pa n ish Ch in e se None / Beginner / Intermediate / Post-intermediate / fluent None / Beginner / Intermediate / Post-intermediate / fluent None / Beginner / Intermediate / Post-intermediate / fluent None / Beginner / Intermediate / Post-intermediate / fluent

ACADEMIC DATA Educational background Elementary education 1 School name Location

Officially required years of schooling Date of entrance and completion

From (yy/mm)

To (yy/mm)

Secondary education Junior high school School name Location

Officially required years of schooling Date of entrance and completion

From (yy/mm)

To (yy/mm)

Secondary education Senior high school School name Location

Officially required years of schooling Date of entrance and completion

From (yy/mm)

To (yy/mm)

Higher education Undergraduate level University name Location

Officially required years of schooling Date of entrance and completion

From (yy/mm)

To (yy/mm)

Degree Major subject Higher education Postgraduate level (1) University name Location
Officially required years of schooling Date of entrance and completion

From (yy/mm)

To (yy/mm)

Degree Major subject Higher education Postgraduate level (2) (if applicable) University name Location
Officially required years of schooling Date of entrance and completion

From (yy/mm)

To (yy/mm)

Degree Major subject

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Current school year/grade: Total years of schooling to date:

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Any research to date e.g. thesis title(s)

Awards / accomplishments

EMPLOYMENT RECORD (Please begin with most recent employment, if applicable.)

Organization 1 Address
Period of employment

From (yy/mm)

To (yy/mm)

Position Type of work

Organization 2 Address
Period of employment

From (yy/mm)

To (yy/mm)

Position Type of work

COURSE REGISTRATION Please select one course for ASC and ALC respectively.
ASEAN Studies Courses (ASC) Please select one of the three courses.

ASC-1: Current Affairs of ASEAN and East Asia ASC-2: ASEAN Economics ASC-3: Cross-cultural Communication

Asian Language & Culture Courses (ALC) Please select one the three courses.
Note) Courses with a very few registrants may be canceled.

Basic Japanese Language and Culture Basic Filipino Language & Culture Basic Spanish and Filipino Culture Basic Thai Language and Culture Basic Chinese Language and Culture

ADDITIONAL INFORMATION for ATW application

Please look carefully at the list below, and make sure that you TICK and ENCLOSE ALL the required application materials. Please download forms from the website: http://www.isc.kyushu-u.ac.jp/astw/

Completed Application Form Academic Transcript (Original) Completed Reference Letter Form

All applicants All applicants All applicants completed by any academic staff member at your current institution other than a language instructor All applicants Title : Why I want to join AsTW (800 to 1000 words) TOEFL or IELTS score for non-native English speakers *We may consider applicants below 520 in order to create more cultural diversity, but that applicant must provide extra proof of English competence. If you submit an extra proof of English competence. only postgraduate students

Essay Language Proficiency Certificate (Copy)

Completed Statement of English Proficiency Form Diploma (Copy)