2021ᖺ

ᖺᗘ᪥ᮏᨻᗓ䠄ᩥ㒊⛉Ꮫ┬䠅ዡᏛ㔠␃Ꮫ⏕⏦ㄳ᭩䠄ᩍဨ◊ಟ␃Ꮫ⏕䠅
2021 APPLICATION FOR JAPANESE GOVERNMENT (MEXT) SCHOLARSHIP
䚷(TEACHER TRAINING STUDENTS)
グධୖ䛾ὀព INSTRUCTIONS
䠍䠊䝍䜲䝥䚸ཪ䛿ᡭ᭩䛝䛷䝤䝻䝑䜽య䛷᫂░䛻グධ䛩䜛䛣䛸䡝 1. Type or write neatly by hand in block letters.
䠎䠊ᩘᏐ䛿⟬⏝ᩘᏐ䜢⏝䛔䜛䛣䛸䡝 2. Use Arabic numerals (0,1, 2, 3, 4…).
䠏䠊ᖺྕ䛿䛩䜉䛶すᬺ䛸䛩䜛䛣䛸䡝 3. Write years in western calendar.
䠐䠊ᅛ᭷ྡモ䛿䛩䜉䛶ṇᘧ䛺ྡ⛠䛸䛧䚸୍ษ┬␎䛧䛺䛔䛣䛸䡝 4. Write proper nouns in full without abbreviation.

䈜ᮏ⏦ㄳ᭩䛻グ㍕䛥䜜䛯ಶே᝟ሗ䛻䛴䛔䛶䛿䚸ᮏዡᏛ㔠䛾㑅⪃䛾䛯䜑 䈜䚷Personal data filled in this application will only be used for scholarship selection
䛻౑⏝䛩䜛䜋䛛䛿䚸≉䛻Email 䜰䝗䝺䝇➼䛾㐃⤡ඛ䛻䛴䛔䛶䛿䚸᥇⏝ᚋ purposes. Contact information such as email addresses of selected applications might
䛻䛚䛡䜛㛵ಀ⪅䛾䝛䝑䝖䝽䞊䜽䜢స䜛䛣䛸ཬ䜃ᚲせ䛻ᛂ䛨᪥ᮏᨻᗓ䜘䜚 be used by the Japanese Government in order to create academic networks or to
ྛ✀᝟ሗ䜢㏦ಙ䛩䜛௨እ䛻䛿౑⏝䛧䛺䛔䚹 send out information when necessary.

䚷(ጣ)䚷Surname 䚷(ྡ)䚷Given name (䢌䢀䢚䢕䢄䡬䢍) Middle name

1. Ặྡ 㺏㺷㺪㺅㺫㺼㺍㺢
SITI HAJAR MOHD RAIS
Name Alphabet

䈜⥛䜚䛿䝟䝇䝫䞊䝖䛾⾲グ䛸ྠ୍䛻䛩䜛䛣䛸䚷䚷㼃rite your name exactly as it appears in your passport.

2. ᛶู 3.䚷፧ጻ≧ἣ 䕕⊂㌟䚷Single
✔
䕕䚷⏨䚷Male䚷䚷䕕䚷ዪ䚷Female
✔
෗┿(4.5cm×3.5cm䠅䚷Photo
Gender Marital Status 䚷䕕᪤፧䚷Married
Paste your photo or digital
4. ᅜ⡠ MALAYSIAN
image taken within 6 months.
Nationality
Write your name and
5. ᪥ᮏᅜ⡠ 䕕䚷↓
✔ 䕕䚷᭷䠖㞳⬺ணᐃᖺ᭶ ᖺ ᭶ nationality on the back of the
2 0
Japanese Nationality 䚷䚷䚷NO 䚷䚷YES: expatriation date yy mm photo.
6. ⏕ᖺ᭶᪥ ᖺ ᭶ ᪥ ᖺ㱋䚷㻔2021/4/1⌧ᅾ䠅 ṓ 6䛛᭶௨ෆ䛻᧜ᙳ䛧䛯෗┿
Date of Birth 1991 yyyy 06 mm 21 dd Age䚷(As of April 1, 2021) 30 yrs 䜎䛯䛿䝕䝆䝍䝹⏬ീ䜢㈞䜛
䛣䛸䚹෗┿䛾⿬㠃䛻ྡ๓䛸
䈜ᛂເ⪅䛿㻝㻥㻤㻢ᖺ㻠᭶㻞᪥௨㝆䛻ฟ⏕䛧䛯⪅䛷䛒䜛䛣䛸䚹 ᅜ⡠䜢᭩䛟䛣䛸䚹
Applicants must have been born on or after April 2, 1986.

7.(1) ⌧ఫᡤ SM SAINS MUZAFFAR SYAH, AYER KEROH MELAKA ᅜྡ MALAYSIA

Current Address Country

䈜⌧ఫᡤ䛜᪥ᮏ䛾ሙྜ䚸⌧ᅾ䛾ᅾ␃㈨᱁䛾✀㢮
If you currently reside in Japan, what is your current visa status?
䈜᪤䛻ᡃ䛜ᅜ䛾ᅾ␃㈨᱁䛂Ọఫ⪅䛃䚸䛂ᐃఫ⪅䛃➼䜢᭷䛧䛶䛔䜛ሙྜ䛷䛒䛳䛶䜒䚸᥇⏝ᚋ䛻䛂␃Ꮫ䛃䛻ኚ᭦䛩䜛ᚲせ䛜䛒䜛䚹䛺
䛚䚸ᅜ㈝እᅜே␃Ꮫ⏕䛾㌟ศ⤊஢ᚋ䛻ᨵ䜑䛶䛂Ọఫ⪅䛃ཪ䛿䛂ᐃఫ⪅䛃䛾ᅾ␃㈨᱁䜢⏦ㄳ䛧䛶䜒ᙜ↛䛻䛿ㄆᐃ䛥䜜䛺䛔ྍ⬟
ᛶ䛜䛒䜛䛣䛸䜢⌮ゎ䛧䛯ୖ䛷⏦ㄳ䛩䜛䛣䛸䚹An applicant with "permanent-resident" or " long-term resident" status must change his/her
status to "student" if selected. Be aware that application for the original status after "student" status is expired may not be necessarily
approved.
䕕䚷ྠୖ䚷Same as above.
(2) Ώ᪥๓ఫᡤ
Your address before 䕕䚷ୗグఫᡤ䛻ኚ᭦䛩䜛䛣䛸䛜☜ᐃ䛧䛶䛔䜛䚷The above 'Current Address' will be changed as follows:
departure for Japan
NO.13A, KAMPUNG SUNGAI JAMBI, 83100 RENGIT BATU ᅜྡ MALAYSIA
PAHAT JOHOR Country

䈜Ώ᪥๓䛾ఫᡤ䛜⌧ఫᡤ䛛䜙ኚ᭦䛻䛺䜛䛣䛸䛜☜ᐃ䛧䛶䛔䜛ሙྜ䛿䚸䛂(2)Ώ᪥๓ఫᡤ䛃䛾䛂ୗグఫᡤ䛻ኚ᭦䛩䜛䛣䛸䛜☜ᐃ䛧
䛶䛔䜛䛃䛻䘠䜢ධ䜜䚸ఫᡤ䜢グධ䛩䜛䛣䛸䚹ኚ᭦䛜䛺䛔ሙྜ䛿䛂ྠୖ䛃䛻䘠䜢ධ䜜䜛䛣䛸䚹If the current address will be changed at
the time of leaving from your country, please check the box of 'The above 'Current Address ' will be changed as follows:' and specify the new
address. If the current address will not be changed, check the box of 'Same as above'.
䈜Ώ᪥๓ఫᡤ䛜ᅜ⡠ᅜ䛸␗䛺䜛ሙྜ䛿䚸ཎ๎䛸䛧䛶Ώ᪥᪑㈝䛜୙ᨭ⤥䛸䛺䜛䛣䛸䜢⌮ゎ䛧䛶䛔䜛䛛䚹If your
䕕䛿䛔 䕕䛔䛔䛘
address before departure for Japan is outside your home country, do you understand that, in principle, an airline ticket to
YES NO
Japan will not provided?
(3) 㟁ヰ␒ྕ
014-3891645 (4) Email sitihajar@mozac.edu.my
Phone number
䈜ྍ⬟䛺㝈䜚䚸Ώ᪥๓䡚᪥ᮏ␃Ꮫ୰䡚ᖐᅜᚋ䛻䜟䛯䜚౑䛔⥆䛡䜛䛣䛸䛜ண᝿䛥䜜䜛Email䜰䝗䝺䝇䜢グධ䛩䜛䛣䛸䚹
You are suggested to write an email address that can be used continuously before, during and after your stay in Japan.

㻝㻌
8. ኱Ꮫཪ䛿ᩍဨ㣴ᡂᏛᰯ䜢༞ᴗ䛧䛶䛔䜛䛛䚹ヱᙜ䛧䛺䛔⪅䛿ᛂເᑐ㇟እ䛷䛒䜛䚹 䕕䛿䛔
✔ 䕕䛔䛔䛘
Have you graduated from a university or a teacher's college? If not, you are NOT eligible to apply. YES NO

䈜༞ᴗド᫂᭩䜢ᥦฟ䛩䜛䛣䛸䚹䚷Please submit certificate of graduation.

9. ⮬ᅜ䛾ึ➼䚸୰➼ᩍ⫱ᶵ㛵䛾⌧⫋䛾ᩍဨཪ䛿ᩍဨ㣴ᡂᏛᰯ䠄኱Ꮫ䜢㝖䛟䠅䛾ᩍဨ䛷䛒䜛䛛䚹ヱᙜ䛧䛺䛔⪅
䛿ᛂເᑐ㇟እ䛷䛒䜛䚹 䕕䛿䛔
✔ 䕕䛔䛔䛘
Are you currently a teacher at a primary or a secondary school or a teacher at teacher's college (excluding universities) in YES NO
your home country? If not, you are NOT eligible to apply.
䈜ᅾ⫋ド᫂᭩䜢ᥦฟ䛧䚸ୗグタၥ㻝㻤㻚䛻ヲ⣽䜢グ䛩䛣䛸䚹䚷Please submit a certificate of employment. Refer to Section 18 below for
details.
10. 㻞㻜㻞㻝ᖺ㻝㻜᭶㻝᪥⌧ᅾ䛷㏻⟬㻡ᖺ௨ୖ䛾⌧ᩍ⫋䞉Ꮫᰯ㐠Ⴀ⤒㦂䛜䛒䜛䛛䚹ヱᙜ䛧䛺䛔⪅䛿ᛂເᑐ㇟እ䛷䛒
䜛䚹 䕕䛿䛔
✔ 䕕䛔䛔䛘
Do you have a total of over five years of teaching/school administrating experience at your current job as of October 1, 2021? YES NO
If not, you are NOT eligible to apply.
䈜ୗグタၥ㻝㻤㻚ཬ䜃㻝㻥㻚䛻ヲ⣽䜢グ䛩䛣䛸䚹䚷Refer to Section 18 and 19 below for details.

11. 䝥䝻䜾䝷䝮ಟ஢䠄ᖐᅜ䠅ᚋ䚸┤䛱䛻ẕᅜ䛻䛚䛔䛶᚟⫋䛧䚸ᩍ⫋䛻䛚䛔䛶◊✲ᡂᯝ䜢ά⏝䛩䜛ពᛮ䛜䛒䜛䛛䚹
ヱᙜ䛧䛺䛔⪅䛿ᛂເᑐ㇟እ䛷䛒䜛䚹 䕕䛿䛔
✔ 䕕䛔䛔䛘
Do you intend to resume to work and utilize the fruits of your research in a teaching capacity after you complete the program YES NO
in Japan and return to your country? If not, you are NOT eligible to apply.

12. 㐣ཤ䛻ᅜ㈝እᅜே␃Ꮫ⏕䛻᥇⏝䛥䜜䛯䛣䛸䛜䛒䜛䛛䚹䛺䛚䚸㐣ཤ䛻ᅜ㈝እᅜே␃Ꮫ⏕䛸䛧䛶᥇⏝䛥䜜䛯⪅ ✔
䕕䛔䛔䛘 䕕䛿䛔
䛿ᛂເᑐ㇟እ䛷䛒䜛䚹
NO YES
Have you been awarded a Japanese Government (MEXT) Scholarship in the past? If "YES", you are NOT eligible to apply.

䈜㐣ཤ䛻ཷ⤥䛧䛯ዡᏛ㔠䛜ᩥ㒊⛉Ꮫ┬ዡᏛ㔠䛻ヱᙜ䛩䜛䛛ྰ䛛୙᫂䛾ሙྜ䛿஦๓䛻ᅾእබ㤋䛻┦ㄯ䛩䜛䛣䛸䚹
If you are unsure whether previously awarded financial aid corresponds to a MEXT scholarship or not, please consult in advance with a
Japanese diplomatic office.

13. ᪥ᮏᨻᗓ䠄ᩥ㒊⛉Ꮫ┬䠅ዡᏛ㔠ไᗘ䛻䜘䜛௚䛾㻞㻜㻞㻝ᖺᗘዡᏛ㔠ᨭ⤥㛤ጞ䛾䝥䝻䜾䝷䝮䛻ే㢪䛧䛶䛔䜛䛛䚹
䛭䜜䜙䛾᪥ᮏᨻᗓ䠄ᩥ㒊⛉Ꮫ┬䠅ዡᏛ㔠䛸䛾ే㢪䛿ㄆ䜑䜙䜜䛺䛔䚹 䕕
✔ 䛔䛔䛘 䕕䛿䛔
Are you applying for any other Japanese Government (MEXT) scholarships for which scholarship payments will begin in NO YES
fiscal 2021? It is not allowed to apply for other Japanese government (MEXT) Scholarships at the same time.

14. (1) ᮏไᗘ䛻䜘䜛ዡᏛ㔠䛸㔜」䛧䚸᪥ᮏᨻᗓ䠄ᩥ㒊⛉Ꮫ┬䠅௨እ䛾ᶵ㛵䠄⮬ᅜᨻᗓᶵ㛵䜢ྵ䜐䠅䛛䜙ዡᏛ㔠

➼䜢ཷ⤥䚸䜎䛯䛿ཷ⤥ணᐃ䛷䛒䜛䛛䚹 䕕
✔
䛔䛔䛘 䕕䛿䛔
Are you receiving or scheduled to be receiving any scholarship from any organization other than the Japanese Government NO YES
(MEXT) (including an organization of your home country government) together with the MEXT Scholarship?

䈜䛂䛿䛔䛃䛾ሙྜ䚸ᮏዡᏛ㔠䛸௚䛾ዡᏛ㔠䛾ే⤥䛿ㄆ䜑䜙䜜䛺䛔䛯䜑䚸ᮏไᗘ䛻᥇⏝ᚋ䛿௚䛾ዡᏛ㔠䛾
ཷ⤥䜢೵Ṇ䛧䛺䛡䜜䜀䛺䜙䛺䛔䛣䛸䜢⌮ゎ䛧䛶䛔䜛䛛䚹 䕕䛿䛔
✔ 䕕䛔䛔䛘
If "YES", do you understand you must cancel other scholarships after selected for MEXT Scholarship Student since it is YES NO
not allowed to receive other scholarships together with the MEXT Scholarship?

(2) ௚䛾ዡᏛ㔠䛻ᛂເཪ䛿௚䛾ዡᏛ㔠䜢ཷ⤥䛧䛶䛔䜛ሙྜ䛿䚸䛭䛾ྡ๓䚸ᮇ㛫䚸㔠㢠➼䜢グ䛩䛣䛸䡝
If you are receiving or applying for other scholarships, please specify the name of the sponsor, scholarship period, scholarship amount, etc.
ዡᏛ㔠䛾ෆᐜ
Describe the scholarship

㻞㻌
15. ᏛṔ䚷䚷Academic record
INSTRUCTIONS
䠍䠊ึ➼ᩍ⫱䛛䜙᭱᪂䛾ᩍ⫱ㄢ⛬䜎䛷ṇつ⏕䛸䛧䛶ಟᏛ䛧䛯ㄢ 1. Write your record from primary education (elementary school) to most recent educational level
⛬䛾䜏グධ䛩䜛䛣䛸䚹ᗂ⛶ᅬ䞉ಖ⫱ᡤᩍ⫱䛿グධ୙せ䚹 attended only as a full-time student. Exclude kindergarten education and nursery school education.
䠎. 䛂༞ᴗᖺ᭶䛃䛿Ꮫᰯ䛾බᘧ䛺༞ᴗᖺ᭶䜢グධ䛩䜛䛣䛸䚹䠄౛䠖 2. Write the official graduation year and month in the space of "To: yyyy/mm". (ex. In case of October intake and
Ꮫᰯ䛾Ꮫ஦ᬺ䛜10᭶ධᏛ9᭶༞ᴗ䛾ሙྜ䚸᭱ᚋ䛾8䡚9᭶䛜ఇᬤ September graduation under the school's academic calendar, put "9 (September)" in the space of "mm" as an official
䛾ሙྜ䜒䛂༞ᴗ᭶䛃ḍ䛿䛂9᭶䛃䛸䛺䜛䚹䠅 graduation month although the term from August to September is a summer break.)
䠏. ᭱⤊ᏛṔ䛜༞ᴗぢ㎸䛾⪅䛿䚸䛂༞ᴗᖺ᭶䛃䛻䛿༞ᴗぢ㎸ᖺ᭶ 3. For those whose status is "Expected to graduate", write expected year and month of graduation in the
䜢グධ䛧䚸䛂༞ᴗぢ㎸䛃ཬ䜃༞ᴗ䛧䛯㝿䛻ྲྀᚓぢ㎸䛾Ꮫ఩䜢㑅ᢥ space of "To: yyyy/mm" and choose "Expected to graduate" and suitable degree expected to obtain
䛩䜛䛣䛸䚹 upon graduation.
䠐. 䛂༞ᴗ≧ἣ䛃䜢䛂䛭䛾௚䛃䛸㑅ᢥ䛧䛯ሙྜ䛿䚸ලయ䛾≧ἣ䜢䛂≉ 4. If the applicant chooses "Other status" in the Status, indicate the detail of status in the Remarks
グ஦㡯ḍ䛃䛻グධ䛩䜛䛣䛸䚹䠄౛䠖㏥Ꮫ䚸ఇᏛ୰䠅 column. (ex. Withdrawal, leave of absence)
䠑䠊䛂኱Ꮫணഛᩍ⫱䛃䛿ᚋᮇ୰➼ᩍ⫱䛻ྵ䜎䜜䜛䡝 5. Preparatory education for university admission is included in upper secondary education.
䠒䠊 䡞኱ᏛධᏛ㈨᱁ヨ㦂䡟䛻ྜ᱁䛧䛶䛔䜛ሙྜ䛻䛿䚸䛭䛾᪨䛂≉グ
6. If the applicant has passed the university entrance qualification, indicate this in the Remarks column.
஦㡯䛃ḍ䛻グධ䛩䜛䛣䛸䡝
䠓䠊䛂㣕䜃⣭䛃䜢䛧䛶䛔䜛ሙྜ䛻䛿䚸䛭䛾᪨䜢䛂≉グ஦㡯䛃ḍ䛻グධ 7. Any school years or levels skipped should be indicated in the Remarks column.
䛩䜛䛣䛸䚹䠄౛䠖ᚋᮇ୰➼ᩍ⫱䠉3ᖺḟ䜢㣕䜃⣭䛻䜘䜚▷ᮇ༞ᴗ䠅 Example: Upper secondary education - Skipped senior year for the early graduation.
䠔䠊ఫᒃ䛾⛣㌿䜔኱Ꮫ䛾෌ධᏛ➼䜢⌮⏤䛻䚸ྠᩍ⫱ㄢ⛬䛷」ᩘ 8. If you attended multiple schools at the same level of education due to moving house or readmission
䛾Ꮫᰯ䛻ᅾ⡠䛧䛶䛔䛯ሙྜ䛿䚸ྠ䛨ḍ䛻」ᩘ䛾Ꮫᰯ䛾ᅾ⡠䜢グ
㍕䛩䜛䛣䛸䚹 to university, write all the schools in the same column.

䠕. ୗグ䛻᭩䛝䛝䜜䛺䛔ሙྜ䛿䚸ู⣬䛻グධ䛩䜛䛣䛸䜒ྍ⬟䚹䛭䛾 9. You may use a separate piece of paper if the space below is insufficient. In such a case, please
ሙྜ䛿䚸ู⣬䛻グධ䛩䜛᪨䜢᫂グ䛩䜛䛣䛸䚹 indicate that the information is on a separate page.
ධᏛཬ䜃༞ᴗ䠄ぢ㎸䠅ᖺ᭶ ಟᏛᖺᩘ ྲྀᚓ㻔ぢ㎸㻕Ꮫ఩
ᩍ⫱ẁ㝵 Ꮫᰯྡ ᡤᅾᆅ ༞ᴗ≧ἣ
Year & month of enrollment & Period of Degree obtained or
Educational level School name Location Status expected to obtain
graduation (expected to graduate) schooling attended
ᕞ䞉┬ State/Province
SEKOLAH ධᏛ
1997 ᖺ
᭶
ึ➼ᩍ⫱ RENDAH JOHOR
From yyyy
01 mm
䠄ᑠᏛᰯ䠅 KEBANGSAAN ᖺ
Primary Education SRI RENGIT ᕷ䞉⏫ City/Town 7 yrs
(Elementary School) ༞ᴗ ᖺ ᭶
BATU PAHAT 2002 12
To yyyy mm

๓ᮇ୰➼ᩍ⫱ SEKOLAH TUN ᕞ䞉┬ State/Province

ධᏛ ᭶
䠄୰Ꮫᰯ䠅 FATIMAH JOHOR 2003 ᖺ 01
From yyyy mm
Lower Secondary ᖺ
Education(Middle ᕷ䞉⏫ City/Town 3 yrs
༞ᴗ ᭶
School/Junior High JOHOR BHARU 2006 ᖺ 12
To yyyy mm
School)
ᚋᮇ୰➼ᩍ⫱ TEMENGGONG ᕞ䞉┬ State/Province
ධᏛ ᖺ ᭶
䠄㧗ᰯ䠅 IBRAHIM GIRLS JOHOR
From
2007 yyyy
01 mm
Upper Secondary SCHOOL ᖺ
Education ᕷ䞉⏫ City/Town 2 yrs
༞ᴗ ᭶
((Senior) High BATU PAHAT 2008 ᖺ 12
To yyyy mm
School)
ᕞ䞉┬ State/Province ༞ᴗ
㧗➼ᩍ⫱ INTERNATIONAL ධᏛ 䕕
SELANGOR 2011 ᖺ 03
᭶ ✔
Graduated
ISLAMIC From
䠄኱ᏛᏛ㒊䠅 yyyy mm
UNIVERSITY ᖺ ༞ᴗぢ㎸ 䕕 Ꮫኈ
Tertiary(Higher) MALAYSIA 5 䕕 Expected
ᕷ䞉⏫ City/Town yrs to graduate Bachelor-level
Education ༞ᴗ ᭶
GOMBAK 2016 ᖺ 09 䛭䛾௚
(Undergraduate) To yyyy mm 䕕 Other status
ᕞ䞉┬ State/Province ༞ᴗ
㧗➼ᩍ⫱ INTERNATIONAL ධᏛ 䕕 ಟኈ
SELANGOR 2017 ᖺ 09 ᭶ ✔
Graduated 䕕
ISLAMIC ✔
䠄኱Ꮫ㝔䠅 From yyyy mm Master-level
UNIVERSITY ᖺ ༞ᴗぢ㎸
Tertiary(Higher) MALAYSIA 2 䕕 Expected
ᕷ䞉⏫ City/Town yrs to graduate
Education ༞ᴗ ᭶ ༤ኈ
GOMBAK 2020 ᖺ 09 䛭䛾௚ 䕕
(Graduate) To yyyy mm 䕕 Other status Doctor-level
ᕞ䞉┬ State/Province ༞ᴗ
㧗➼ᩍ⫱ ධᏛ ᖺ ᭶ 䕕 Graduated
ಟኈ
䕕
䠄኱Ꮫ㝔䠅 From yyyy mm Master-level
ᖺ ༞ᴗぢ㎸
Tertiary(Higher) 䕕 Expected
ᕷ䞉⏫ City/Town yrs to graduate
Education ༞ᴗ ᖺ ᭶ ༤ኈ
(Graduate) 䛭䛾௚ 䕕
To yyyy mm 䕕 Other status Doctor-level

2021ᖺ ᖺ㻝㻜᭶1᪥᫬Ⅼ䛾㏻⟬䛾Ꮫᰯᩍ⫱ಟᏛᖺᩘ ᖺ
Total years of schooling attended as of October 1, 2021 yrs

≉グ஦㡯
Remarks

㻟㻌
16. ኱Ꮫཪ䛿ᩍဨ㣴ᡂᏛᰯ䛷ᑓᨷ䛧䛯ᑓ㛛ศ㔝䠄䛷䛝䜛䛰䛡ලయⓗ䛻᭩䛟䛣䛸䡝䠅
Past field of specialized study in a university or teacher training school (Be as specific as possible.)
SECONDARY SCHOOL GUIDANCE AND COUNSELING

17. ⴭ᭩䚸ㄽᩥ䠄༞ᴗㄽᩥ䜢ྵ䜐䡝䠅䛜䛒䜜䜀䛭䛾㢟ྡ䚸ฟ∧♫ྡ䚸ฟ∧ᖺ᭶᪥䚸ฟ∧ሙᡤ䜢グධ䛩䜛䛣䛸䡝
State the titles or subjects of books and papers (including graduation thesis) authored by applicant, if any, with the name, address of publisher and
the date of publication.
~

(2) ໅ົඛ
TEACHER SEKOLAH MENENGAH SAINS MUZAFFAR SYAH
Name of the school where
18.(1) ⌧⫋ you are employed
Your status/occupation (3) ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town

Location MALACCA AYER KEROH

(4) ໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 2017 01 㹼 To 2021 9 5 9
Duration yyyy mm yyyy mm yrs mons

(5) ⌧ᅾ䛾⫋ົෆᐜ
Present type of work

䠄ᩍᤵ⛉┠ཪ䛿䚸ᴗ
ົ䛾ෆᐜ䛻䛴䛔䛶᭩
䛟䛣䛸䚹
䈜኱Ꮫ䛾ᩍဨ䛿⏦ㄳ
䛷䛝䛺䛔䚹䠅
(Describe teaching
subjects or work duties.
䈜University faculty
members are NOT
eligible to apply.)

19. ⫋Ṕ (ึ➼䞉୰➼ᩍ⫱ᶵ㛵䛾ᩍဨཬ䜃ᩍဨ㣴ᡂᏛᰯ䠄኱Ꮫ䜢㝖䛟䠅䛾ᩍဨ䛸䛧䛶䛾⫋Ṕ䚷䈜⌧⫋䛿タၥ18.䛻グ㍕῭䛾䛯䜑⌧
⫋௨๓䛾⫋Ṕ䛜䛒䜜䜀䜢グ㍕䛩䜛䛣䛸䚹ᮏḍ䛻䛚䛡䜛ᅾ⫋ᖺᩘ䛿⌧⫋䛾໅ົᮇ㛫䠄18.(4))䜢ྵ䜑䛯ྜィ䜢グ㍕䛩䜛䛣䛸䚹)
Employment record as a teacher at primary, secondary educational institutions or teacher training schools (excluding universities)
䈜Write the record before the most recent employment as the most recent one has been already stated in 18 "Your status/occupation".
Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(1)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(2)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(3)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
㻠㻌
 Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(4)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(5)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(6)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
Ꮫᰯྡ ᡤᅾᆅ ᕞ䞉┬State/Province ᕷ䞉⏫䚷City/Town
Name of school Location
⫋ົෆᐜ ᙺ⫋ྡ
(7)
Job Content Position
໅ົᮇ㛫 ᖺ ᭶ ᖺ ᭶ ᖺ 䛛᭶
From 㹼 To
Duration yyyy mm yyyy mm yrs mons
㏻⟬ᅾ⫋ᮇ㛫䠄㻞㻜㻞㻝ᖺ㻝㻜᭶㻝᪥⌧ᅾ䠅䚷䈜タၥ㻝㻤㻚ཬ䜃㻝㻥㻚䛾ྜィ䛿㻡ᖺ௨ୖ䛷䛒䜛䛣䛸䚹 ᅾ⫋ᖺᩘ ᖺ 䛛᭶
Total period of employment (As of October 1, 2021)䚷*The sum of 18 and 19 must be over 5 years. Duration yrs mons
䛣䛾◊✲ィ⏬䛿㑅⪃䛾㔜せ䛺ཧ⪃䛸䛺䜛䛾䛷䚸◊✲ィ⏬䜢300Ꮠ௨ୖ䛷ヲ⣽䛻グධ䛩䜛䛣䛸䚹グධ䛿䝍䜲䝥ཪ䛿ᴠ᭩䛻䜘䜛䜒䛾䛸
䛧ᚲせ䛺ሙྜ䛿ู⣬䜢㏣ຍ䛧䛶䜒䜘䛔䡝䜎䛯䚸㓄⨨ᕼᮃ⏦ㄳ᭩䛻グ㍕䛩䜛ᕼᮃ኱Ꮫཬ䜃ศ㔝䛿ᮏ◊✲ィ⏬䛸㛵㐃䛵䛡䛯ෆᐜ䛸䛩
䜛䛣䛸䚹
䛺䛚䚸ᕼᮃ䛩䜛◊✲䝔䞊䝬䛜」ᩘ䛒䜛ሙྜ䚸◊✲ィ⏬䛿䠎✀㢮䜎䛷グ㍕䛩䜛䛣䛸䚹䛭䛾ሙྜ䚸ㄞ䜏䜔䛩䛔䜘䛖㐺ᐅ㡯┠❧䛶䛩䜛䛣
䛸䚹䠄౛䠖➨୍ᕼᮃ䛸䛧䛶ᩘᏛᩍ⫱䛾◊✲䜢ᕼᮃ䛧䚸➨஧ᕼᮃ䛸䛧䛶⌮⛉ᩍ⫱䛾◊✲䜢ᕼᮃ䛩䜛ሙྜ䚸ᮏḍ䛻䛭䜜䛮䜜䛾◊✲ィ⏬
䜢グ㍕䛧䛶䜘䛔䚹䛣䛾ሙྜ䚸䛂ᩍဨ◊ಟ␃Ꮫ⏕䝁䞊䝇䜺䜲䝗䛃䛛䜙ᕼᮃ䛩䜛ᩘᏛᩍ⫱ཬ䜃⌮⛉ᩍ⫱䛾◊ಟ䝥䝻䜾䝷䝮䜢ᥦ౪䛧䛶䛔
䜛኱Ꮫཬ䜃ศ㔝ྡ䜢㑅ᢥ䛧䚸䛂㓄⨨ᕼᮃ኱Ꮫ⏦ㄳ᭩䛃䛻グ㍕䛩䜛䛣䛸䚹䠅
┦ᙜ䛾᪥ᮏㄒ⬟ຊ䜢᭷䛩䜛⪅䛿䚸᪥ᮏㄒ䛻䜘䜚グධ䛩䜛䛣䛸䡝
In more than 150 words, state the outline of your major field of study and research plan. This section will be used as one of the most important
references for selection. Your statement must be typewritten or written in block letters. Any relevant documents may be attached if necessary.
Selected universities and fields on the PLACEMENT PREFERENCE APPLICATION FORM should be related to each research plan.
Those who desire multiple research topics may indicate as many as two research plans. If you do so, please indicate them clearly by itemizing such
selections. (Example: If you select mathematics education research as your first choice and scientific education research as your second, you may
20.᪥ᮏ䛷䛾◊✲ィ⏬ indicate their respective research plans in this column/space. In doing so, be certain to select a university/teaching field from "the Course Guide"
䚷Your research plan in that offers the mathematics and science education research training program that you desire and indicate it in "the PLACEMENT PREFERENCE
Japan APPLICATION FORM".)
If possible, write in Japanese.
䠄኱Ꮫཪ䛿ᩍဨ㣴ᡂ ศ㔝(1)
Ꮫᰯ䛷ᑓᨷ䛧䛯ᑓ㛛 Teaching field
ศ㔝䛸䛾㛵㐃䛻䛚䛔
䛶䛷䛝䜛䛰䛡ලయⓗ ◊✲䝔䞊䝬(1)
䛻᭩䛟䛣䛸䡝䠅 Research Theme
(Write in connection with
the past field of
specialized study in a
university or teacher
training schol. Be as
specific as possible.)

㻡㻌
 㻔◊✲ィ⏬㻔㻝㻕䛾⥆䛝 Continued from the previous page of the research plan (1).㻕

20.᪥ᮏ䛷䛾◊✲ィ⏬ ศ㔝(2)
䠄⥆䛝䠅 Teaching field
䚷Your research plan in
Japan (continued from ◊✲䝔䞊䝬(2)
the previous page) Research Theme

㻢㻌
21. ㄒᏛຊ
ㄞ䜐⬟ຊ Reading ᭩䛟⬟ຊ Writing ヰ䛩⬟ຊ Speaking ⫈䛟⬟ຊ Listening
Language ability
᪥ᮏㄒ
Japanese
ⱥㄒ
English
䛭䛾௚
( )
Others
䈜䠏䛛䜙䠌䛷⮬ᕫホ౯䛩䜛䛣䛸
䠏䠙ඃ㻌Excellent 䠎䠙Ⰻ Good 䠍䠙ྍ Fair 䠌䠙୙ྍ Poor
Self-rate on a scale of 3 to 0.
22. ᪥ᮏㄒ⬟ຊ䠄㈨᱁䠅 ᪥ᮏㄒ⬟ຊヨ㦂 䢖䢉䢚䢕 䛭䛾௚
Japanese language qualifications JLPT level Other
䈜⏦ㄳ⪅䛾Ặྡ䚸᪥ᮏㄒ⬟ຊ䜢ド᫂䛷䛝䜛ෆᐜ䠄䝺䝧䝹䚸䝇䝁䜰➼䠅䛜グ㍕䛥䜜䛯᪥ᮏㄒ⬟ຊ䜢ド᫂䛩䜛㈨᱁ド᫂᭩䛜ᥦฟྍ⬟䛺ሙྜ
䛾䜏䚸ᮏḍ䛻グධ䛾ୖ䚸ド᫂᭩䜢ᥦฟ䛩䜛䛣䛸䚹ᙜヱ᝟ሗ䛜グ㍕䛥䜜䛯ド᫂᭩䛾ᥦฟ䛜䛷䛝䛺䛔ሙྜ䛿䚸ᮏḍ䛿✵ḍ䛸䛩䜛䛣䛸䚹Please
enter the information and submit a copy of the certificate of Japanese-language ability only if you have a certificate that shows your name and level/score. If
you will not be able to prepare a copy of the certificate, do not enter the information in this item.

iBT
23. ⱥㄒ⬟ຊ䠄㈨᱁䠅 䛭䛾௚
TOEFL IELTS
English language qualifications Other type Other
( )
24. 䛭䛾௚ㄒᏛ⬟ຊ䠄㈨᱁䠅 䛭䛾௚
Other language qualifications Other
25. ྠకᐙ᪘ḍ䠄Ώ᪥䛩䜛ྠకணᐃ䛾ᐙ᪘䛜䛔䜛ሙྜ䛻グධ䛩䜛䛣䛸䚹䠅
Accompanying Dependents (Provide the following information if you plan to bring any family members to Japan.)
䈜䛺䛚䚸ྠక⪅䛻ᚲせ䛺⤒㈝䛿䛩䜉䛶᥇⏝⪅䛾㈇ᢸ䛷䛒䜛䛜䚸ᐙ᪘⏝䛾ᐟ⯋䜢ぢ䛴䛡䜛䛣䛸䛿┦ᙜᅔ㞴䛷䛒䜚㈤㈚ᩱ䜒㠀ᖖ䛻๭㧗䛻䛺
䜛䛾䛷䛒䜙䛛䛨䜑ᢎ▱䛧䛶䛚䛟䛣䛸䚹䛣䛾䛯䜑䚸᥇⏝⪅䛿䜎䛪༢㌟䛷᮶᪥䛧䚸㐺ᙜ䛺ᐟ⯋䜢ぢ䛴䛡䛯ᚋ䚸ᐙ᪘䜢࿧䜃ᐤ䛫䜛䛣䛸䚹All expenses
incurred by the presence of dependents must be borne by the grantee. Applicants are advised to take into consideration the various difficulties in finding
accommodation and its great expenses. Therefore, those who want to accompany their families are well advised to come alone first and let them come after
suitable accommodation has been found.

Ặྡ Name ⥆᯶ Relationship ᖺ㱋㻌Age ᅜ⡠㻌Nationality

26. ⥭ᛴ䛾㝿䛾ẕᅜ䛾㐃⤡ඛ䚷䚷Emergency contact person to be notified in applicant's home country.

Ặྡ ⥆᯶
Name Relationship
⌧ఫᡤ ⫋ᴗ
Current address Occupation
㟁ヰ␒ྕ䠋㻲㻭㼄␒ྕ
Email
Phone / Facsimile number

27. ᪥ᮏ䜈䛾Ώ⯟ཬ䜃ᅾṔ䚷䚷Past visits or stays in Japan List from your most recent visits.

ᮇ㛫䚷Period Ώ⯟┠ⓗ䚷Purpose
ᖺ ᭶ ᖺ ᭶
From yyyy mm
䡚 To yyyy mm

ᖺ ᭶ ᖺ ᭶
From yyyy mm
䡚 To yyyy mm

䚷⚾䛿㻞㻜㻞㻝ᖺᗘ᪥ᮏᨻᗓ䠄ᩥ㒊⛉Ꮫ┬䠅ዡᏛ㔠␃Ꮫ⏕ເ㞟せ㡯䛻グ㍕䛥䜜䛶䛔䜛஦㡯䜢䛩䜉䛶஢ゎ
䛧䚸ୖグ䛾㏻䜚⏦ㄳ㈨᱁䜢‶䛯䛧䛶䛔䜛䛣䛸䜢☜ㄆ䛾ୖ䚸⏦ㄳ䛧䜎䛩䚹
䚷I understand and accept all the matters stated in the Application Guidelines for Japanese Government (MEXT)
Scholarship for 2021 and upon confirmation of my qualifications for application as stated above, I hereby apply for
this scholarship.
⏦ㄳ⪅⨫ྡ ⏦ㄳᖺ᭶᪥ 20䚷䚷䚷ᖺ 䚷䚷䚷᭶ 䚷䚷䚷䚷᪥
/ /
Applicant's signature Date of application year month date

㻣㻌