KANDEN-SS SCHOLARSHIP APPLICATION FORM 2017

(This application form should be written clearly and completed in English. Typing is preferable)

Application form can be downloaded from http://www.hcmut.edu.vn/ Applicant number (fill

The original and all required documents should be submitted at the below address: by selection
committee):
Contact and Mailing Address:
Ms. Thai Hoang Chi An - External Relations Office
Address: Room 102 Building A5 - 268 Ly Thuong Kiet, District 10, HCMC
E-mail: thchian@hcmut.edu.vn
All pages 1 through 3
IMPORTANT DATES: must be thoroughly
(1)Submission deadline of applications: 31st of May annually filled in
(2)Submission deadline of candidate list to KSS: mid of June annually
(3)Application screening date: end of June annually
(4)Notification of scholarship awarding: early September annually
(5)Scholarship awarding ceremony: September or October annually

It is advisable to provide detailed information and description for each item below, and attach supporting
documents when necessary

SECTION 1 - PERSONAL INFORMATION

Applicant Name:

___i_______________ ___________________ ____Thnh____________ ID Photo 3 x 4cm

Last name First name Middle name

Gender Male Female Date of birth Month: 01__ Date_03_Year_1996____

Present Address Telephone:

141/14 Le Duc Tho Street, Ward 15, Go Vap District, Ho
Chi Minh City Mobile: +84 163 8520483

Permanent Address: An Thuong Hamlet, Vinh Thinh Village, Email address:1410746@hcmut.edu.vn

Vinh Tuong Town, Vinh Phuc Province
Preferred contact address: (can tick more than one)
Present Address Permanent Address Email Telephone Mobile

SECTION 2 - EDUCATION
A. CURRENT UNIVERSITY
Name of university : Ho Chi Minh Student ID
1410746
Department/Faculty Major of Study

Current Academic Year First Second Third Fourth Fifth

Academic record : Talent Class:
7.87 Yes No
the 2nd semester of the last academic year :

the 1st semester of the current academic year: 7.89

B. GENERAL
1. Honors/Awards/Scholarship History (Include amounts and effective dates )
From (DD/MM/YY) To(DD/MM/YY) Name/Description of Scholarship
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 KANDEN-SS SCHOLARSHIP APPLICATION FORM 2017

2. Extracurricular/Community Activities (Include school and community activities in order of importance)

From (DD/MM/YY) To(DD/MM/YY) Name/Description of Activities

3. English language skills

Speaking Listening Writing Reading
Excellent Good Excellent Good Excellent Good Excellent Good
Fair Poor Fair Poor Fair Poor Fair Poor
4. Japanese language skills
Excellent Good Excellent Good Excellent Good Excellent Good
Fair Poor Fair Poor Fair Poor Fair Poor

SECTION 3 FAMILY INFORMATION (Father, mother, wife/husband, children, brothers and sisters)
Relative Full-name Age Occupation Work place or present address

SECTION 4 - SCHOLARSHIP

1. Have you ever taken a Japanese course?

Yes ________________________________ No
(If yes, please attach the certificate(s) of Japanese Proficiency)
2. Have you ever participated in a movement/ activity aiming at contributing /promoting the exchange of
culture between Japan and Vietnam?
Yes ________________________________ No
(If yes, please specify or attach certificate(s) of the movement/activity participation)
3. Have you ever received any scholarship from Kanden-SS Scholarship Fund?
Yes ________________________________ No
(If yes, please specify the type of scholarship)
4. Do you agree to participate in Kanden SSs business?
Strongly agree Agree No idea Disagree

SECTION 5 DOCUMENT CHECKLIST

Document checklist: Compulsory

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 KANDEN-SS SCHOLARSHIP APPLICATION FORM 2017
1 Application form
2 Academic record of the 2nd semester of the last academic year and of the 1 st semester of the current
academic year
3 At least one recommendation letter of the dean or head of the department or research supervisor or
class head teacher
4 Any certificate
5 Japanese proficiency certificate (if any)

CERTIFICATION AND RELEASE AUTHORIZATION

I certify that all the information included in this application and attached documents is complete, correct and
true to the best of my knowledge. I authorize the release of information concerning my background, academic
and financial status to confirm and verify this application.

Signature: Date: (day)_____/(month)______/(year)______

Note: Kanden-SS Scholarship Program 2017 will not consider illegible, incomplete application packages,
or documents reaching the given address after the deadline (both of original and scan documents).
Applications will not be returned.

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