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1 For University Use Applicant No Application Form for Programs in English at Komaba (PEAK) 1. Course Selection Please select the course you would like to apply from the drop-down menu. Make sure to choose the correct course. International Program on Environmental Sciences 2. Personal Details Full Name kyo University Komaba In English Last / Family / Surname First name Middle name *as written in your passport / government issued ID card Name in Chinese Character (if applicable) Photo (4cmx3cm) Date of Birth 2001/01/01 Age (as of August 31, 2019) 18 yyyy/mm/dd Write your name on the back. Gender Female Place of Birth kyo Japan Nationality (ies) US China *If you have Japanese nationality, please check the box: city country Please state all nationalities Addresses @provider.com @provider.com *If possible, please type two addresses. Phone (Home) Phone (Mobile) country code number inc. area code country code number inc. area code Postal Address during Jan May 2019 Permanent Home Address (if different from above) Be sure to enter your address carefully including apartment name etc. if appropriate San Francisco CA USA city state / province country zip / postal code city state / province country zip / postal code 3. Preferred Major Cities for the Second Screening Please note your preferred major cities for the second screening: San Francisco, LA * Interviews in kyo are scheduled for February 9, 2019 (Other venues will be determined and announced later). If you wish to be interviewed in other cities, please understand that compliance with your preference cannot be guaranteed. 4. Application Fee Please indicate your chosen method of payment and enclose the payment receipt with this form. Method of Payment: By credit card online Receipt attached? 1

2 5. English Proficiency Test If you choose No, please provide at least one form of English language qualification from the three options. 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? No If not, provide your English language qualification details (Complete all that apply). TOEFL IELTS Proficiency Test Date Test Type Score/Result Official Results Details 2017/03 ibt /08 Academic module 7.5 Registration number: TRF number: Cambridge English 2018/03 CAE Grade B Candidate ID number: Language Assessment Ensure you include this Candidate Secret Number: Ensure you include this 6. Other Language Ability (if applicable) Language Reading / Writing Listening / Speaking Basic Intermediate Advanced Basic Intermediate Advanced Chinese Japanese French Please include all your relevant school qualifications, including those exams that you have not yet taken, but 7. Official Examination Results for Academic for Ability which (Standardized you will eventually Examinations) submit results. You may Please refer to the sample application form. leave the scores blank if you have not taken them yet (only for SAT, ACT and AP). Name of Examination Date Subject Score/Result Actual/ Predicted SAT 2018/12 Math SAT 2018/12 Reading & Writing SAT Subject 2017/10 Math Actual SAT Subject 2017/10 Chemistry 780 Actual IB 2019/05 Math HL 7 Predicted IB 2019/05 Chemistry HL 7 Predicted IB 2019/05 Biology HL 7 Predicted IB 2019/05 English SL 7 Predicted IB 2019/05 History SL 6 Predicted IB 2019/05 Economics SL 6 Predicted IB 2019/05 TOK/EE 2 Predicted GCE A level 2019/06 Math A Predicted GCE A level 2019/06 Chemistry A Predicted GCE A level 2019/06 English A Predicted 2

3 8. Educational Background (Primary and Secondary schools) 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, Period of Attendance Primary Language of Instruction Secondary (upper) My high school Postal Address, Phone Number, 2016/ /06 English Secondary (lower) My junior high school Postal Address, Phone Number, 2013/ /06 English Primary My primary school Postal Address, Phone Number, 2007/ /06 Chinese Please make sure you provide all the information for each school. If you have skipped grade(s), please check the box below. tal : 12 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: 9. Other Education (Post Secondary, Language Schools, Other Institutions, if applicable) Name of Institution Country Period of Attendance () () yyyy/mm yyyy/mm Currently Enrolled? Qualification 10. Prizes and Awards Obtained (if applicable) List prizes and awards. Enclose documentary evidence of each of your prizes or awards. Name of Awarding Body Date Name of Award 3

4 11. Work Experience (if applicable) Name of Organization Position Full-time/ Postal Address, Website Part-time 12. Volunteer Work / Extra-curricular Activities (if applicable) Name of Organization Position Responsibility Postal Address, Website 13. Military Service Status (if applicable) Please provide details about your military service status. Military Service No obligation 14. Referees 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 Address Simon Chemist XXX high school Chemistry teacher simonchemist@school.com Please make sure if your academic referee is qualified to evaluate your academic ability. Referee 2 A person who can evaluate your character. Name of Referee Name of Institution Position Address Eleanor Unrelated XXX high school School counselor eleanor@school.com 4

5 15. Additional Information Include any additional information that you feel may be relevant to your application along with details of any additional documents you are attaching. If you are attaching any additional documents such as prize certificates or anything that you feel might strengthen your application, please indicate which attachments you have enclosed in this box. You can also provide any comment relevant to your application in this box. 16. Declaration All personal information submitted to the University of kyo is appropriately managed in compliance with the Act on the Protection of Personal Information Held by Incorporated Administrative Agencies, etc. and the The University of kyo Rules on Measures for Proper Management of Retained Personal Information, etc. Personal information related to the applicant will be used for the purpose of the admissions process, announcement of results and enrollment procedure. It will also be used to improve future selection procedures. Furthermore, the personal details of applicants admitted to the University of kyo will 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 scholarships d) Levying of tuition and other fees The University of kyo, in accordance with applicable national laws and university policies, does not discriminate on the basis of race, color, national origin, religion, sex, disability, age, medical condition, ancestry, marital status or sexual orientation. 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 University of kyo 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. 2018/08/01 Name (in block letters) Signature Date (yyyy/mm/dd) PLEASE MAKE SURE TO ADD YOUR NAME, SIGNATURE AND THE DATE!! 5

6 Please tick all the boxes for items that you Please check the following before have enclosed mailing out. with your application * Application Form - Signed and Dated? Essay Form - Signed and Dated? Application Document Check List Official School Transcripts (Original or certified copy) - Sealed in a school envelope? Official Actual / Predicted Examination Results for Academic Ability (Standardized Examinations) How to submit Who may submit Tick Post Applicant Post Applicant Post Post/ Online High school High school/ Testing Agency 5* Official Test Scores for English Proficiency (if applicable) Post/ Online Testing Agency 6 Certificate of (Expected) Graduation Post High school 7** Evaluation Forms (two forms) - Sealed in an envelope with the referee s signature across the seal? Post Referee 8 Photo 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 28, //Please arrange all the documents in the order listed above// PEAK Undergraduate Admissions office The University of kyo Komaba, Meguro-ku kyo , JAPAN 6