2013

Scholarship Initial Registration Form

2013/4/1
Any false declaration of information will result in applications for all scholarships not being accepted.
Please take care that the information entered about financial supporters is the same as in your application for admission.

Automatic Input

Name in full (in English, in capital letters) Date of Birth 19 85 / (yyyy/mm/dd) Student ID No.
Status of Residence

CHAN
Family Name First Name

SAN
Middle Name

sample sampl PHOTO

Photocopies Accepted

Age

27

Sex (Male/Female)

Male

80000000 College Student

Nationality Period of Stay

Chinese 20 14 / 3 / 31 N/A Master's

Keio Taro Year Year

Faculty of Graduate School of Major:

N/A Economics
Academic Advisor:

Department of Degree Type

Please write the expiration date indicated on your Residence Card.

2nd

XXX Economics

Enrollment on Present Program (yyyy/mm) Repeat/ 20 10 / 9 Leave of absence

20 10 /
-

Completion/Expected Completion of Present 20 14 / Program (yyyy/mm)

20 11 / 20 12 / 20 /

3 3

Because of Because of Because of

absence: military service repeat: poor results

20 11 / 20
Current Address

/
-

108

8345

208 xx Building, Mita, Minato-ku, Tokyo

Make sure you complete this section if you have repeated some part of your course, or if you taken a leave of absence. Please provide the contact information of an acquaintance in Japan with whom you keep in daily touch, such as a friend on your course. Indication of language ability: very goodYou have no difficulty in understanding lectures or research seminars in this language. goodYou can read and write in this language. fairYou can communicate in daily situations in this Please do not write in this space.

E-mail address() ***@a8.keio.jp E-mail address() ***@adst.keio.ac.jp Tel (Home)

03
-

****

****

Mobile

090

****

****

Emergency 270 Contact (in Japan) Name Contact Address in Home Country

****
Relationship

*** Chiba-shi, Chiba-ken

Uncle

Yamaoka Taro

****

**

****

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

Name Chan i Relationship Father

**-********

About your language ability (Please indicate the appropriate level) Japanese very good good fair poor
Japanese Language Proficiency Test Level English Other Other Chinese Korean Native Native N1 Date obtained (yyyy/mm) fair fair poor poor

2010

12
T0EFL iBT 100

very good good Native very good good very good good

Qualification Qualification Qualification

fair poor

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

For Official Use Only

*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.

2013
Name in full:

Scholarship Initial Registration Form CHAN SAN

Student ID No.

Date

80000000

2013/4/1
(unitYEN
Total amount of monthly income

Monthly IncomeFill out average of monthly income from April 2012 to March 2013 *In case of new students who enroll in 2013 spring semester, fill out expected monthly income from April 2013.
1.Allowance <A> 25,000
<A><B>

1.Allowance 2.Part-Time Job 2.Part-Time Job 2.Part-Time Job (Wage Income) (Wage Income) (Wage Income) <B> <A> <B> <C> 10,000 10,000 30,000
<A><B><C>

3.Loan
0

4.Scholarship 5.Other Income 65,000 0

0 30,000

130,000

Fill out expeted monthly income from April 2013, if you are a new student of

*Don't include tuition assistance from your parents or guarantee in the allowance above. *Please note that students who receive the allowance above 90,000 yen are not eligible for the Honors Scholarship (JASSO). Give specific information in the form below about your income. 1.Allowance<A> From Chan i Allowance<B> From YamaokaTaro Employer XX store-XX ten 2.Part-Time Part-Time Job<B> Employer XX Chinese language school Part-Time Job<C> Employer
*Fill out the weekly average of hours worked during semester. Total Amount 3.Loan

(unitYEN Relationship Relationship

Type of Work Type of Work Type of Work

Part-time worker Teacher

Total

Father Uncle 9 9

*Working more than 28 hours a week is prohibited

hrs/week hrs/week hrs/week hrs/week

Hours from part-time work during holidays or full-time jobs before enrollment are

Lender (Relationship)

5.Other Income

Details

Please include in "2.Part-Time Job" all income from work such as language tuition and translation, and the salary for any research assistance. Submit proof of earnings for all part-time work (e.g., copy of tax withholding slip, employment agreement or other confirmation of employment). *Please fill the total amount in the space B, if you have more than two jobs.

Monthly Expense Fill out your monthly average Type of Keio Accommodation Company Accommodation for International Students Accommodation Private Apartment Accommodation for International Students (except Keio Accom.) Home Stay Living with parents, family or guarantor (free of rent) Please check the Student Accommodation (for both Japanese and International Students) applicable box Other ( Housing Expense Monthly Rent common-area fee, management fee Detail: Spouse Child No. Yes. Brother/Sister Housemate(s) Friend 1 Other Reason if you do not pay rent Amount of rent you pay 32,000 House Size e.g., 8-tatami, Kitchen, Bathroom 8-tatami, kitchen, BR Name of Accommodation/Apartment XX Building Monthly Average Food 18,000 Monthly Average Books/Stationery 15,000 Please include payment for student commuter pass. (Monthly Avedage) Transportation Monthly Average 5,000 Reason Daily Expenses Monthly Average 10,000 seminar-related activities
Allowance to Family
Monthly Average Monthly Average Monthly Average

0 32,000 10,000

Recipient

Other Expenses Savings

Detail Total Savings

400,000

Cell-phone, Internet Reason Doctal course March 31, 2013

About Payment of Academic Fees (Tuition & Other Fees at Keio University) Paid Academic Fees I have already paid for Fall Semester/20 12 academic year as of Payer of paid-up Family Academic Fees Financial Supporter

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

How do you get money, if you paid part of the amount? Payment for 2013
Academic Fees
Payer of Academic Fees due to be paid from now (Check all that apply )
How do you get money, if you will pay part of the amount?

(Check all that apply )

Scholarship which covers full tuition & other fees

Self Savings Loan from whom Other I already paid up Family Financial Supporter

Part-Time Job

I will pay by

2013 / 10 / 30 (yyyy/mm/dd)
Amount of Tuition Fees

Amount of 2013Academic Fees

535,100

490,000

Scholarship which covers full tuition & other fees

Self Savings Loan Other

from whom

Part-Time Job

New students and students who enrolled in April 2013 should write expected monthly income from April 2013. Students who have already been studying in Keio before April 2013 should write average of monthly income. If you were working full time, please write this in "Part -Time Job". All amounts must

In case you live with your family in Japan, fill out the income and expense that concerns you only. Concerning the financial support you receive (for academic fees, your living costs, etc.), include this amount in the space "1.Allowance".

2013
Name in full:

Scholarship Initial Registration Form CHAN SAN

Student ID No.

3
Date

80000000

2013/4/1

Financial Support Please attach the forms to certify the latest income. Current Place of Address Financial RelationEmployment/ Name in full Age Nationality Supporter ship Country/Regio School n/City Family Member Chan I Father 54 Chinese China, Qingdao, Shandong China XX Bank Oh En Mother Spouse 54 Chinese
China, Qingdao, Shandong

2012 Annual Income (in local currency)

2012 Annual Income (in yen)

100,000 yuan 0

\ \ \ \ \ \

1,500,000

Housewife

Financial Sponsor (Except for Family) Yamaoka Taro Uncle

50

Japanese

Japan, XX, Chiba

Yamaoka Inc.

5,000,000yen

5,000,000

You must submit documents to certify the latest income stated in these spaces. For the details, please refer to "Documents Required for the Scholarship Initial Registration 2013 (Explanation for

\ Please mark with a circle the financial supporter you gave in your application for admission. Personal History Include in your personal history periods in education (from high school), employment, training, housekeeping, etc. * Be careful not to leave any period of time unaccounted for. Country/ Graduated or passed high school China/Shandong Qingdao High School 2005 / 6 (yyyy/mm) Name of Upper Region equivalence test
Secondary/High School

2005 2006 2010 2011 2012

/ 10 / / / / / / / / / 4 4 9 4

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

- 2006 - 2010 - 2012 -

/ / / / / / / / / /

3 3 3

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

Country/ Region Country/ graduated Keio University: Economics Region Country/ enrolled Keio Graduate School of Economics: Master's Program Region Country/ absence: English study program Region Country/ studying Keio Graduate School of Economics: Master's Program Region Country/ Region Country/ Region Country/ Region Country/ Region Country/ Region

completed X Japanese Language preparatory class

Japan/Tokyo Japan/Tokyo Japan/Tokyo

China/Qingdao

Japan/Tokyo

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

Plan after Graduation Check all that apply

Enter Graduate School (M.A.) |Name of University Enter Graduate School (Ph.D.) |Name of University Keio Graduate School of Economics: Doctoral Program Work in Japan Industry and Company where you want to work
Return to home countryWrite your plan in detail in the space below, if you have already decided.

Country/Region Country/Region Japan/Tokyo

Other
Health Condition Check the box. Do you have any health problems? Yes Please have a medical check-up at the Health Center at Mita Campus. No

Details, if "Yes"
Special Note
Space to Include Details of Awards, Punishments, Qualifications, Strengths, etc.

In November 2003, I won the Principal Award in the Speech Contest at XX Japanese Language School In October 2009, I won an excellence award for a presentation titled "XXXXX"
I have been interested in Japanese culture and have been learning how to wear Kimono and the tea ceremony since I was in the first year of college. I want to introduce good things about Japan to people in my country, when I return.

2013
Name in full:

Scholarship Initial Registration Form CHAN SAN

Student ID No.

Date

80000000

2013/4/1

History of Scholarships you have received. (Only at Keio University)

Please list scholarships received such as the Honors ScholarshipKeio University Scholarship, Keio Graduate School Scholarship

and the Yamaoka Scholarship. You do not need to list scholarships which you are just applying for now. Period Monthly Name of Scholarship received in the past Amount of Stipend /Annual (yyyy/mm - yyyy/mm)
Honors Scholarship Honors Scholarship

Extention

Monthly Monthly

48,000 65,000

2007 2010

/ / / / / / / /

4 4

2008 2011

/ / / / / / / / / / /

3 3

Name of Scholarship (you will receive from April 2013 or are currently receiving
N/A

/ / /

For married students: Scholarships your spouse currently receives. Name of Scholarship
N/A Monthly Amount of Stipend /Annual

Period (yyyy/mm - yyyy/mm)

Extention

/ /

/ /

Future Scholarships you want to apply for (just for reference: Applications for each scholarship must be made). Please check the box. Honors Scholarship Keio University Scholarship or Keio Graduate School Scholarship Desired Desired Monthly Scholarships Provided by Private 70,000 Possibility of exchange activities Foundations/Local Governments Amount Conditions

Other

Please explain your financial situation and clarify your scholarship need.

Pledge To: 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. 2013 Signature / 4 / 1 (yyyy/mm/dd)
You must make your signature by hand. Do not use a computer.

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