Application Form 1

The Yamagata-Andes Nations' Double Triangle Program (For Long-term)

President of Yamagata University

I will apply to the title program as follows.

Full Name Passport Number Expiration Date

Birthday (day/month/year) School Year or Cicle Sex Student Number of the University
male female
The Name of University and Faculty Division or Course

Telephone Number Mail Address for Contact

Certificate of the English Ability

□TOEIC　（　　　　　　　　　points）　　　　□TOEFL　iBT　（　　　　　　　　　　points）　□IELTS　（　　　　　　　　　class）
□CEFR　 （　　　　　　　　　　　）　　　　　□The Other Certificate（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）
（１）　The Reason of the Participation in This Program

（２）　The Aim of the Participation in This Program

（３）　The Plan of Study or Job after the Participation in This Program

（４）Past History of Illnes and Morbidity to be Noted （only who meet the condition）

　Signature

How did you know this program?

□Poster □Web site of the Yamagata University □Facebook □friends
□Professor/ University's staf □Others（　　　　　　　　　　　　　　　　　　　　　　　　　）
 Application Form 2

Desired Study / Research Content

Full Name

（１）Desired Faculty / Graduate School of the Yamagata University

Faculty / Graduate School of

（２）Desired Term for Study (day / month / year )

　　　　　　　　　　　From 　　　　　/ / 　　　　～　To　 / /

（３）Your Major or Speciality

Faculty / Graduate School of Course / Major field of

（４）Desired Study Content （Please fill in as concrete as possible）