Uniindex

THE MATSUMAE INTERNATIONAL FOUNDATION
Mailing Address: 4-14-46, Kamiogi, Suginami-ku, Tokyo 167-0043 JAPAN
Document #1
APPLICATION FORM FOR 2011
Fill out in English by typewriter or handwriting with block letters and complete all questions.
1 I would like to apply for a fellowship for the period of
months, from to
(Month/Year) (Month/Year)
2 Nationality
(Present) (Previous)
Height cm
3 Name in full
Mr./ Ms. ／
(Family Name) (Given Name)
4 Date and Place of Birth, and Age
Years old
(Month) (Day) (Year) (Place)
5 Postal Address to be used by the Foundation
Fax： E-mail：
6 Please list members of immediate family.
Name Age Relationship
7 Education
Period Name of Institution Main Subjects Studied Degree
8 Topic of Ph.D. Thesis
9 Current educational activity, if any
Name of Institution Starting date and expected completion.
Place Main Subjects Expected Degree
10 Previous Stays in Japan
Period Place Purpose Financed by
(MIF USE ONLY)
Photo
4.0×3.0cm
Please write name
and nationality on
the reverse side of
photo
11 Research Project in Japan
[Title]
[Brief Summary] Please enclose its Details as “Document #2.”
12 Language (Evaluate using Excellent, Good, Fair and Poor)
Writing Reading Speaking
English
13 Current Employment (Position, Name of Organization)
14 Future Professional Plans
in country
15 Previous Employment
Institution Location From-To Position Type of Work
16 Please list major awards or fellowships which you have received.
Name of Award Organization Period Type of Award
17 Please list major awards or fellowships for which you are currently applying or plan to apply.
Name of Award Organization Period Type of Award
18 Japanese Host Scientist (Please enclose letter of invitation as “Document #8”.)
Name
Position or Title
Institution
Address
Tel:
19 Name of the international airport nearest your home.
20 I fully understand and agree to the “Fellowship Announcement”, and I hereby certify that all the
descriptions above are true, and that I am of sound health and not physically handicapped in any way
which would prevent me from carrying out research in Japan.
Date: Handwritten Signature:
(An unsigned application form is not accepted.)
Check-List
* Please read the Fellowship Announcement carefully before submitting application documents.
No. APPLICATION DOCUMENTS ✓
#1 Application Form with photograph (4×3 cm)
#2 The Research Project
#3 Complete List of Publications
#4 Reprint(s) of Most Important Publication(s)
#5 Personal History (Curriculum Vitae)
#6 Letter of Recommendation
#7 A Certified Copy of Academic Certificates
#8 Invitation Letter by the Host Scientist