1

Full Name

In English Last / Family / Surname First name Middle name *as written in your passport / government issued ID card

Name in Chinese Character (if applicable)

Date of Birth Age (as of August 31, 2020)

yyyy/mm/dd

Gender

Nationality (ies)

Please state all nationalities

*If you have Japanese nationality, please check the box:

E-mail Addresses

*If possible, please type two email addresses.

Phone (Home) Phone (Mobile)

country code number inc. area code country code number inc. area code

Postal Address during

Jan – May 2020

city state / province country zip / postal code *Please write down an accurate postal address including postal code. Please notify PEAK Undergraduate Admissions Office promptly if there is a

change of address.

Please select the course you would like to apply from the drop-down menu. Make sure to choose the correct course.

Please note your preferred major cities for the second screening:

Please provide details about your military service status.

Military Service

2020 Application Form for Programs in English at Komaba (PEAK)

For University Use

Applicant No.

Paste your photo

(4cmx3cm)

Write your name on

the back.

1. Personal Details

2. Course Selection

3. Preferred Major Cities for the Second Screening

* Interviews in Tokyo are scheduled for February 11, 2020 (Other venues will be determined and announced later).If you wish to

be interviewed in another city, please understand that compliance with your preference cannot be guaranteed.

4. Military Service Status (if applicable)

2

BLANK

PAGE

3

Describe your complete educational background from primary to the most recent or current secondary schools. If there are not enough

rows, please attach your complete educational background on a separate piece of paper using the same format and type in “see

attachment” on the first row of the chart below.

Please write school names both in English and the native language.

Category School Name Postal Address, Phone Number,

School Website

Period of Attendance

(yyyy/mm)

Primary Language

of Instruction

Primary From

To

From

To

From

To

From

To

From

To

From

To

From

To

Total : years*

*In principle, you need to have completed, or expect to complete, 12 years of education in order to apply for this program. Please refer to “2.Eligibility“ of the Application Guidelines.

*If you have skipped grade(s), please check the box:

Name of Institution Country Period of Attendance

(From) (To) yyyy/mm yyyy/mm

Currently

Enrolled?

Qualification

5. Educational Background (Primary and Secondary schools)

6. Other Education (Post Secondary, Language Schools, Other Institutions, if applicable)

4

List prizes and awards. Enclose documentary evidence of each of your prizes or awards.

Name of Awarding Body Date (yyyy/mm) Name of Award

Name of Organization From

(yyyy/mm)

To

(yyyy/mm)

Position Full-time/

Part-time

Postal Address, Website

Name of Organization From

(yyyy/mm)

To

(yyyy/mm)

Position Responsibility Postal Address, Website

Referee 1 A teacher at your school who can evaluate your academic ability. (Those applying for the Japan in East Asia Program

must have a humanities or a social science teacher to fill in the form. Those applying for the Environmental Sciences Program must have a teacher from a science-related field to fill in the form.)

Name of Referee

Name of Institution

Position

E-mail Address

Referee 2 A person who can evaluate your academic ability.

Name of Referee

Name of Institution

Position

E-mail Address

8. Work Experience (if applicable)

9. Volunteer Work / Extra-curricular Activities (if applicable)

10. Referees

7. Prizes and Awards Obtained (if applicable)

5

Did you receive an English-medium education for at least 4 years of the first 6 years of education and at least 5 years of the second

6 years of education? If not, provide your English language qualification details (Complete all that apply).

Proficiency Test Date (yyyy/mm) Test Type Score/Result Official Results Details

TOEFL iBT/PBT Registration number:

IELTS Academic module

TRF number:

Cambridge English

Qualifications

C1 Advanced/

C2 Proficiency

Candidate ID number: Candidate Secret Number:

Language Reading / Writing Listening / Speaking

Basic Intermediate Advanced Basic Intermediate Advanced

Please refer to the sample application form.

Name of Examination Date

(yyyy/mm)

Subject Score/Result Actual/

Predicted

11. English Proficiency Test

12. Other Language Ability (if applicable)

13. Official Examination Results for Academic Ability (Standardized Examinations)

6

Include any additional information that you feel may be relevant to your application along with details of any additional documents

you are attaching.

All personal information obtained by the University of Tokyo (UTokyo) through the application process, which is consented to by the applicant in accordance with a privacy statement, is managed in compliance with the “Act on the Protection of Personal Information Held by Incorporated Administrative Agencies, etc.” and the “The University of Tokyo Rules on Procedures for the Appropriate Management of Personal Information Retained by the University”. Personal information is never disclosed to any third party other than the third party platform operating company, Mypage, which stores and processes applicants’ personal data in accordance with its own confidentiality policy and in agreement with UTokyo. Personal information included in the application documents and Mypage is used in UTokyo’s screening process, the announcement of results, the allocation of scholarships and enrollment procedure. Personal information may be used as statistical data for the improvement of the application process and development of the PEAK curriculum. In all cases, the applicant’s anonymity is guaranteed. Also, please note that the personal details of applicants admitted to UTokyo may be used for:

a) Academic affairs (student registration, academic advising, etc.)b) Student welfare services (health care, careers advice, tuition exemption, scholarship applications, etc.)c) Allocation of scholarshipsd) Levying of tuition and other fees

In accordance with applicable national laws and university policies, UTokyo does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, disability, age, medical condition,or marital status.

By signing this declaration, I certify that all information submitted in the admission process, including the application, the personal essays, all supplements and any other supporting materials are my own work, factually true, and honestly presented. I authorize the UTokyo to use my data for identifying multiple applications and checking records of my studies as a student in other institutions. I understand that I may be subject to a range of possible disciplinary actions, including, but not limited to, admission revocation or expulsion, should any of the information I have certified to be false.

Name (in block letters) Signature Date (yyyy/mm/dd)

15. Declaration

14. Additional Information

7

2 Essay Form

Post Applicant - Signed and Dated?

3 Official School Transcripts (Original or certified copy)

Post Applicant/ High school - Sealed in a school envelope?

4* Official Actual / Predicted Examination Results for Academic Ability (Standardized Examinations)

Post/ Online

Applicant/ High school/ Testing Agency

5* Official Test Scores for English Proficiency (if applicable) Post/ Online

Applicant/ Testing Agency

6 Certificate of (Expected) Graduation Post Applicant/ High school

7** Evaluation Forms (two forms)

Post Applicant/ Referee - Sealed in an envelope with the referee’s signature across the seal?

8 Photo

- Pasted it on application form?Post Applicant

9 Receipt of payment of the Application Fee Post Applicant

10 School Profile Post Applicant

11 Other Documentary Evidence of Achievements (if applicable) Post Applicant

* can be sent separately through testing institution

** If you cannot include them and wish to submit directly from the referee, please notify

PEAK Undergraduate Admissions Office by November 27, 2019.

//Please arrange all the documents in the order listed above//

PEAK Undergraduate Admissions office

The University of Tokyo

3-8-1 Komaba, Meguro-ku

Tokyo 153-8902, JAPAN

Please check the following before mailing out.

Application Document Check List

How to submit

Who may submit

Tick

1 Application Form

Post Applicant - Signed and Dated?