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様式２　Form2
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学生交流協定に基づく留学申請書
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Application Form for Ibaraki University Exchange Program
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Section 1　基礎項目 Basic Infromation入力欄　Fill inSample
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1氏名1
（パスポートの表記）		姓Name1
(same as passport)		Family name in alphabetIBARAKI
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2名Given name in alphabetMANABU
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3ミドルネームMiddle initial(s) in alphabetN/A
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4氏名2
（日本語表記）		漢字Name2
(Japanese notation)		Name in Kanji or Chinese characters茨城大　学
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5カタカナName in Japanese Katakanaイバラキダイ　マナブ
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6生年月日 年/月/日Date of birthyyyy/mm/dd//1999/3/31
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7国籍NationalityChinise
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8性別GenderMale
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9所在国名　CountryChina
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10現住所AddressNo.1 Liangmaqiao Dongjie, Chaoyang District, Beijing 100600
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11電話番号　+(国別コード)-○○-××-□□□□Telephone number+( International Code ) - ○○ - ×× - □□□□+-+86-10-8531-9800
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12E-maiE-mailStudentExchange01@ml.ibaraki.ac.jp
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13緊急連絡先氏名Emargency contactNameIbarakidai Wataru
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14続柄RelationshipFather
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15住所 Adress2520 Massachusetts Avenue N.W., Washington D.C., 20008-2869, U.S.A.
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16電話Telephone number+-+1-202-238-6700
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17E-mailE-mailIOIU@ml.ibaraki.ac.jp
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18在籍大学　大学名Home institutionInstitution NamePartner UniversityClick ▼ and select the College
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19学部Faculty/School at Home institution人文学部／College of Humanities
College of Humanities and Social Sciences
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20学科Course / Major at Home institution情報文化学科／Course for Informantion and CultureCollege of Education
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21卒業予定年月日Date of expected graduation//1999/3/31College of Science
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22在籍年次 2/3/4学部／修士／博士Grade freshman/sophomore/junior/seniorUndergraduate/Mastser/DoctorClick ▼ and select a degree levelUndergraduateCollege of Engineering
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23（交換留学期間開始時の）学年School Year at the beginning of the exchange program period 2/3/4Click ▼ and select a school year at the beginning of the exchange program3College of Agriculture
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24希望プログラムProgram I: Ibaraki Japanese Language and Culture Program
日本語初級・初中級履修希望者は、英語でのコミュニケーション能力を有すること		ProgramProgram I: Ibaraki Japanese Language and Culture Program
Language Eligibility: Students who wish to attend a beginner's course are required to have English communication skills. 		Click ▼ and select a program typeProgram I
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Program II: General Program
日本語能力試験N2以上の日本語能力を有すること		Program II: General Program
Language Eligibility: Students must havear at least N2 level of Japanese language proficiency (Undergraduate)
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25受入希望学部Program II 希望者のみ:
受入希望学部を選択		CollegeStudents who wish to participate in Program II :
Please select the College in which you wish to enroll.
Click ▼ and select a Period Option
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26受入期間オプション1　2027年4月～2027年8月
（2027年度前期）		PeriodOption 1 from Apr. 2027 to Aug. 2027
(1st semester in AY2027)		Click ▼ and select a Period OptionOption1 04.2027-08.2027Option1 04.2027-08.20275
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オプション2　2027年4月～2028年2月（2027年度前期、後期）Option 2 from Apr. 2027 to Feb. 2028
(1st and 2nd semester in AY2027)		Option2 04.2027-02.202811
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オプション3　2027年9月～2028年2月（2027年度後期）Option 3 from Sep. 2027 to Feb. 2028
(2nd semester in AY2027)		Option3 09.2027-02.20286
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オプション4　2027年9月～2028年8月（2027年度後期、2028年度前期）Option 4 from Sep. 2027 to Feb. 2028
(2nd semester in AY2027 and 1st semester in AY2028) 		Option4 09.2027-08.202811
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27英語能力native speakerEnglish proficiencyNative speakerClick ▼ and select your English proficiencyNear native
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near nativeNear native
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highly proficientHighly proficient
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good commandGood command
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basic communication skillsBasic communication skills
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noneNone
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28英語テストスコアTOEFLEnglish Language Test ScoreTOEFLITP 600
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29TOEICTOEIC900
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30Other testOther testIELTS 8.5
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31語学力（日本語）JLPT N5～N1、または無しJapanese Language ProficiencyJapanese Language Proficiency Test　Level N5 ～ N1 or NoneClick ▼and select your levelN3Click ▼ and select
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32JLPT以外のテストの点数The test name and score othere than JLPT/JPT/500Yes
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33日本語学習歴

*「はい」と答えた場合は、以下の欄「学習歴」も入力すること		有／無／独学Have you ever received Japanese language education at a acertain institution before.

*If you answer "Yes", fill in the following blank ”Institution”.		Yes
No
No, but I have studied Japanese by myself.		Click ▼ and selectYesNo
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34日本語学習に使ったことがある教科書の名前The name of textbook which you have used for learning Japanese・みんなの日本語-初級Ⅰ(Minna no Nihongo-Elementary Japanese Ⅰ)
・初級日本語　げんきⅡ(GENKI: An Integrated Course in Elementary Japanese I )
No, but I have studied Japanese by myself.
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35日本語学習歴1機関Institute　1Institute where you have studied Japanese 1Name of the Institute 1Partner University
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36期間1　自Period 1 [from]//2024/8/1
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37期間1　至Period 1 [to]//2025/1/31
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38日本語学習歴2機関Institute　2Institute where you have studied Japanese 2Name of the Institute 2Partner University
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39期間2　自Period 1 [from]//2025/2/1
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40期間2　至Period 1 [to]//2025/6/30
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41日本語学習歴3機関Institute　3Institute where you have studied Japanese 3Name of the Institute 3N/A
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42期間3　自Period 1 [from]////
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43期間3　至Period 1 [to]////
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　Section 2　留学保険加入に関する申告　Declaration for Study Abroad Insurance
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下記内容を確認し、□を■にしてください。
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After confirming the following description, please blacken each box.
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私は、交換留学生は、渡航後に下記（１）（２）の保険の両方に加入しなければならないことを理解しました。
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I understand that an exchange student have to subscribe to both of the following insurances (1) and (2) just after arrival.
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(1) 国民健康保険　National Health Insurace
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(2) 学生教育研究災害傷害保険　Personal Accident Insurance for Students Pursuing Education and Research (PAISPER)
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また、これらの保険の他に、日本での留学生活全般を広く補償する留学保険への別途加入を強く勧められていることを理解しました。
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I understand that it is strongly recommended to join a student insurance program in addition to these insurances to widely compensate for the study abroad life in Japan.
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　　Section 3　チェックリスト　Check List
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私は、本申請書(様式2)のスキャンデータ及びエクセルデータと共に、下記添付書類を提出します。
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I hereby submit this application (Form2)（both of scaned copy and excel format) and have attached all the following compulsory documents:
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□Not attached／■Attached
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様式2　学生交流協定に基づく留学申請書（PDFなどのスキャンデータ）
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(Form 2) “Application Form for Ibaraki University Exchange Program”（Scanned copy such as PDF)
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様式2　学生交流協定に基づく留学申請書 （エクセルデータ）
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(Form 2) “Application Form for Ibaraki University Exchange Program”　（Excel format）
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□様式3　日本での学習・研究計画書
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(Form 3) “Study plan in Japan”
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□様式4　健康診断書
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(Form 4) Certificate of Physical Examination
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□在籍証明書
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Certificate of Enrollment
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□成績証明書
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Academic transcript
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□パスポートの写し（顔写真があるページ）
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Photocopy of passport (page with face photo and information)