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Application form for students from the Association of Pacific Rim Universities (APRU) member universities APPLICATION FOR KEIO UNIVERSITY SUMMER SCHOOL AT UNIVERSITY OF WASHINGTON INSTRUCTIONS 1. The application should be typewritten, if possible, or neatly handwritten in block letters. 2. Numbers should be in Arabic numerals. 3. All years should be written using the Western Calendar. 4. Proper nouns should be written in full and not be abbreviated. (Sex) 1. Full name in native language male (Family name) (First name) (Middle name) (Family name) (First name) (Middle name) Female In Roman block capitals 2. Nationality 3. Date of birth Year Month Day Paste a passport size photograph of yourself taken within the past 6 months. Write your name and nationality in block letters on the back of the photo. Age 4. Present status: the name of the university and the faculty you enroll 5. Present address and telephone number, facsimile number, e-mail address Present address: ( 6cm × 4cm ) Telephone/facsimile number: E-mail address: 6. Educational background Higher Education Name and Address of Year and Month Amount of time Diploma or School of Entrance and spent at the Degree awarded, Completion attended school Major subject Name From years and Undergraduate Level To months Location Graduate Level Name From years and To months Location 1/2 7. English language proficiency: Evaluate your level and insert an X where appropriate in the following blanks. Excellent Good Fair Poor Listening Reading Writing Speaking 8. Statement of purpose, your goal of this summer school, your study plan *Person to be notified in applicant's home country in case of emergency: 1) Name in full: 2) Address: with telephone number, facsimile number, e-mail address Present address: Telephone/Facsimile number: E-mail address: 3) Occupation of the Person: 4) Relationship: Date of application: Applicant's name(in Roman block capitals) : Applicant's signature: 2/2