Application for Tuition Fee Exemption

[ For International Students ]
Gakusei-Shien-ka
( Division of Student Affairs )
Application for Tuition Fee Exemption
Exemption of Tuition Fee for First Half 2015
Tuition Fee Exemption is for those who have financial difficulty in paying tuition fee. Applications will be
carefully screened. When it is accepted, ALL or HALF the amount of tuition fee is to be exempted.
As the tuition being asked to be paid twice a year, the first half for Apr.- Sep., and the latter half for Oct.Mar., the application should be made for each time. The screening is made among all the applicants
based on our criteria.
Important information for the application can be found on the bulletins board located in Lecture Bldg.
and Gakusei-Shien-ka, and on our website (http://www.nagaokaut.ac.jp/j/gakuseishien/gakuseishien.html)
before each school term starts.
1. Qualification
(1) One who has an outstanding academic record, and has financial difficulty in paying Tuition Fee.
(2) One who him/herself has been damaged by natural disaster in JAPAN within six months so that
making Tuition Fee payment is difficult.
* If you want to know the academic standard for application, please contact Gakusei-Shien-ka.
Those who correspond to any of the conditions below cannot apply.
(1) Those who are repeating a year.
(2) International students who receive scholarship from Monbukagakusho (MEXT) or home
government.
2. Application (Documents must arrive within the period below)
March 2 (Mon) 2015 - March 31 (Tue) 2015
Bring a complete set of documents, directly
to Divivsion of Student Affairs (Gakusei-Shien-ka)
(open Monday to Friday, 9:00 a.m. to 5:00 p.m.).
* Late application, arriving AFTER the last day is NOT accepted for any reason. If you cannot make
the application during the period, please come and talk to Gakusei-Shien-ka beforehand.
−1−
3. Documents Required
(1) Application Form for Tuition Fee Exemption (Designated Form)
(2) Form for Family Condition (Designated Form)
▽ The data in the form should be that at the time of application.
▽ IF you have no family member living in Japan, write your name on the very top box and no
need to fill other spaces.
▽ IF your family is in Japan, list their name, relation, age and occupation, in the box for ‘family
member(s) except students’. IF any of them are student, list them in the ‘family member(s) in
school except you’. Give correct information on name of school, year, school type, etc.
Submit a Ju-min-hyo (issued at city hall upon your request) of your entire household by the
end of April 2015, as an evidence.
▽ Space within the bold lines is for office use. Please do not fill in.
(3) Certificate of Salary (Designated Form) or a Copy of `Gensen-Choshu-Hyo’ of 2014
ONLY those who have a part time job at the time of application should submit.
(4) Recommendation Letter from Supervisor (Designated Form)
Please ask your current or prospective supervisor to make it for you.
4. Notice of the Result of Screening
Result of the screening is to be notified at Gakusei-Shien-ka during July 2015.
When your application is not accepted, you need to make the payment by an appointed date, using
the payment sheet handed to you; commission fee is charged additionally by bank upon payment.
When any question regarding the application,
please contact Gakusei-Shien-ka Division of Student Affairs ):
Ground floor, Administration Bldg. #2
E-mail: [email protected]
−2−
年月日
(yy, mm, dd)
平成２７年度前期分
授業料免除願
Application for Tuition Fee Exemption
長岡技術科学大学長殿
To President of Nagaoka University of Technology
【Applicant】
課程
grade
所属
専攻第学年
Major
Period of
Enrollment （西暦）
年
月
学籍番号
Student Number
本人氏名（自署）
Name
〒
同住所
Address
携帯電話番号
Phone Number
保証人氏名（自署）
〒
同住所
* No need to fill in
電話番号
下記により、授業料免除を御許可くださるよう保証人の連署をもって申請します。
I apply for Tuition Fee Exemption as follows;
記
理由（申請者本人が具体的に記入のこと）
Reason for Application (to be written concretely)
〔授業料免除用 for Tuition Fee〕家庭調書
Form for Family Condition
学籍番号 Student ID Number （Name in Katakana ）
通学 1．自宅通学
区分 2．自宅外通学
Name of Applicant
e
x
c
e
p
t
S
T
U
D
E
N
T
S
F
A
M
I
L
Y
Relatio
nship
氏名 Name
Age
Relatio
nship
氏名 Name
Age
Occupation and Name of Institution/Company
M
E
M
B
E
R
S
c
h
o
o
l
在学学校 Name of School
設置区分
１．国立
２．公立
３．私立
学校名 Name of school
（ Year）
１．国立
２．公立
３．私立
学校名 Name of school
（ Year）
１．国立
２．公立
３．私立
学校名 Name of school
（ Year）
１．国立
２．公立
３．私立
学校名 Name of school
（ Year）
(
M
E
M
B F
E A
e R M
x
I
c S L
e
Y
)
p
t
給与所得以外の所得
千円
給与所得
千円
i
Y n
O
U
本人 You 父 Father 母 Mother
千円千円千円千円千円
特
別
控
除
関
係
※ Salary: salary for regular/part time job, directors' remuneration, aid allowance
1．自宅通学
2．自宅外通学
1．自宅通学
2．自宅外通学
1．自宅通学
2．自宅外通学
Name
Income
except Salary
(
)
yen/month
Scholarship Period
Occasional Income
Total
年月より
※ Income except Salary: income for trade, farming, forestry, fishery, etc.
Other Income: Income as rent, interest, allotment, etc.
※ Please fill in the TOTAL income amount from Jan. - Dec. of the previous year,
disregarding figures below 1,000 yen (ex. Income of 20,000 yen should be written as 20).
母子・父子世帯
父無死亡・離婚・別居（年月）
母無死亡・離婚・別居（年月）
障害者のいる世帯
続柄（）手帳番号（続柄（）手帳番号（長期療養者のいる世帯
続柄（）療養期間年月から
続柄（）療養期間年月から
主たる家計支持者別居
住居・光熱水費等の世帯
）
）
from
０：該当せず
１：該当
人
yy
mm
受給額（年額）千円
家族数
学力
合計千円生活保護
独立生計者
合計千円
千円
火災・風水害・盗難等の被害年月日・内容（平成年月日）
被害を受けた世帯
被害額千円
※ Space within
2．自宅外通学
Scholarship you will
award FY 2015 (if any)
Other Income
I
N
C
O
M
E
1．自宅通学
Your Scholarship Condition
千円
Salary
F
A
M
I
L
Y
通学区分
1.Elementary School
2.Junior HighSchool
3.High School
4.University 5.Other
1.Elementary School
2.Junior HighSchool
3.High School
4.University 5.Other
1.Elementary School
2.Junior HighSchool
3.High School
4.University 5.Other
1.Elementary School
2.Junior HighSchool
3.High School
4.University 5.Other
人
０：不適格
１：適格
１：有り
１：有り
申請区分
１：一般２：家計
３：学力４：事由
合計千円５：事情（家計支持者死亡）
６：事情（災害）
７：事情（その他）
is for office use. Please don't fill in.
※ Space for family members should be filled in the data of only those who live in JAPAN.
[Sample]
家庭調書 Form for Family Condition
学籍番号 Student ID Number （Name in Katakana ）
1
e
x
c
e
p
t
S
T
U
D
E
N
T
S
3 3 8 1 2 3 4 Name of Applicant
F
A
M
I
L
Y
Relatio
nship
WIFE
氏名 Name
NAGAOKA HANAKO
Age
ナガオカタロウ
通学 1．自宅通学
NAGAOKA TARO
区分 2．自宅外通学
Occupation and Name of Institution/Company
30 HOUSEWIFE
M
E
M
B
E
R
Relatio
nship
S
c
h
o
o
l
BROTHER
氏名 Name
NAGAOKA HAJIME
Age
20
１．国立
２．公立
３．私立
１．国立
２．公立
３．私立
)
１．国立
２．公立
３．私立
i
Y n
１．国立
２．公立
３．私立
O
U
在学学校 Name of School
設置区分
(
M
E
M
B F
E A
e R M
x
I
c S L
e
Y
p
t
給与所得以外の所得
千円
給与所得
千円
本人 You 父 Father 母 Mother WIFE
BROTHER
千円千円千円千円千円
400
Salary F
A
M
I
L
Y
I
N
C
O
M
E
特
別
控
除
関
係
通学区分
1.Elementary School
学校名 Name of school
2.Junior HighSchool
○○ University
3.High School
（ 1 Year） 4.University 5.Other
1.Elementary School
学校名 Name of school
2.Junior HighSchool
3.High School
（ Year）
4.University 5.Other
1.Elementary School
学校名 Name of school
2.Junior HighSchool
3.High School
（ Year）
4.University 5.Other
1.Elementary School
学校名 Name of school
2.Junior HighSchool
3.High School
（ Year）
4.University 5.Other
1．自宅通学
2．自宅外通学
1．自宅通学
2．自宅外通学
1．自宅通学
2．自宅外通学
1．自宅通学
2．自宅外通学
Your Scholarship Condition
千円
Scholarship you will
award FY 2015 (if any)
300
※ Salary: salary for regular/part time job, directors' remuneration, aid allowance
Name
Income
except Salary
( JASSO
Other Income
80,000
400
300
2015
※ Income except Salary: income for trade, farming, forestry, fishery, etc.
Other Income: Income as rent, interest, allotment, etc.
※ Please fill in the TOTAL income amount from Jan. - Dec. of the previous year,
disregarding figures below 1,000 yen (ex. Income of 20,000 yen should be written as 20).
母子・父子世帯
父無死亡・離婚・別居（年月）
母無死亡・離婚・別居（年月）
障害者のいる世帯
続柄（）手帳番号（続柄（）手帳番号（長期療養者のいる世帯
続柄（）療養期間年月から
続柄（）療養期間年月から
主たる家計支持者別居
住居・光熱水費等の世帯
）
）
年 4 月より
from
０：該当せず
１：該当
人
yy
mm
受給額（年額）千円
家族数
学力
合計千円生活保護
独立生計者
合計千円
千円
火災・風水害・盗難等の被害年月日・内容（平成年月日）
被害を受けた世帯
被害額千円
※ Space within
yen/month
Scholarship Period
Occasional Income
Total
)
人
０：不適格
１：適格
１：有り
１：有り
申請区分
１：一般２：家計
３：学力４：事由
合計千円５：事情（家計支持者死亡）
６：事情（災害）
７：事情（その他）
is for office use. Please don't fill in.
※ Space for family members should be filled in the data of only those who live in JAPAN.
For Tuition Fee
アルバイト等収入証明書
Certificate of Salary
長岡技術科学大学
Nagaoka University of Technology
所属
課程・専攻
Major
年
Grade
氏名
Name
上記の者の賃金支払（見込）額等は、下記のとおりであることを証明します。
記
１．賃
金：
円（日額・月額・年額）
２．日
数：
日／月
３．開始日：
年
月
日
４．期
年
月
日 ∼
間：
年
月
日
（期間が決まっている場合は記入）
平成
年
月
日
所在地
代表者名
（会社名）
印
○
年
殿
３．推薦理由
氏名
２．本学入学前の経歴等
年
月
所属
日
入国
１．推薦する学生の課程（専攻）、学年、氏名
記
課程・専攻
所属（系）
職
名
推薦者氏名
（自署または押印）
下記により、平成２７年度前期分授業料免除について推薦します。
長岡技術科学大学長
私費外国人留学生授業料免除推薦書
Recommendation Letter for Tuition Fee Exemption
平成
年
月
日
５．その他特記事項等
４．本人の経済的状況等

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