If applicable, write your name in Chinese character

Write your name in CAPITAL LETTERS , first name , Family name middle name

Name

Date of birthYear Month day Age

Nationality

Lab’s Name

Prospective supervisor’s Name

male female

Status of residence

Photo

Taken within the last 3 months Face the camera directly with full face in view without a hatheight 4cm x width 3cm

Student ID NO.

Subject name

No.

No.Subject name

Eligibility

MonthYear Name of University

MonthYear Name of University

Faculty Major

National Public Private Others

Major

Name of Graduate school

Course( Master or Doctoral)

Graduate

Expected Graduate

Completed

Expected to be completed

Medical License( Country) Issue date of the license

Year Month Year Month

Year Month

Year Month Year MonthDay

Day

Day

Name of Hospital, Institution etc.

Working periods

Present address ZIP CODE

Present address

Landline phone number : Email address

Cell phone Number

Name of Hospital( Country)

General

Entrance Continue

Screening for working adults

①

②

③ ④ ⑤

⑥ ⑦

⑧ ⑨

⑩ ⑩a⑩c ⑪

⑪a

⑪b

⑩b ⑫

⑬

⑭

⑯

⑮

⑰

⑬A

⑬B

⑬C

⑯a⑯b⑯c

Name of department

Status

(ⅰ)(ⅱ)(ⅲ)(ⅳ)

(ⅴ)(ⅵ)

National Public Private Others

RESUME

Name of Elementary school

Name of Junior high school

Name of High school

Name of University

Higher

Academic

Elementary

Secondary

YearDate of Enrollment Date of Completion( expected)

Year YearYearMonth

Year

Year

Year

Month

Year YearYearMonth Month

Year YearYearMonth Month

Year YearYearMonth Month

Year YearYearMonth Month

Year YearYearMonth Month

Name of Hospital, Institution, Company

LEVEL

Doctor, Nurse etc./ Chief doctor, Chief

nurse etc.

Date of Entrance Date of resignationName of working place Status/Position

Name of school

I hereby certify that information I wrote above is true

NAME (Signature)

Date Year Month Day

Date Year Month Day

Bachelor’s degree Master’s degree Doctoral Degree

⑱

⑲

⑳

㉑

㉒

Academic

University level

Graduate school

Name of Graduate school Year

⑱a ⑱b ⑱c

⑲a ⑲b ⑲c

Standard duration of completion Duration of being a student

Duration of Working

Name of Rewards and Punishments

Degree you acquired

(including acquisition as of 2019 Sep.) Title of the degree Title of the degree Title of the degree

Manual_ how to write application form “Doctoral Course in Medical Sciences”

①選抜方法（Examination Category）: Please tick applicable one.②氏名（Name）: Please fill out your name③生年月日 （Date of birth)④年齢（Age）⑤性別（Gender): Please circle applicable gender.⑥国籍（Nationality）⑦在留資格（Status of residence）：If you live in Japan and have residence card, please fill out.⑧学籍番号（Student ID No.）& ⑨在籍身分（Status at Tohoku University）:

If you belong or have ever belonged to Tohoku University as a student including a research student,please fill out current or past student ID No. and student status (e.g. BB524655, undergraduatestudents). If not applicable to this section, just leave it blank.

⑩志望分野（Laboratory you would apply for）:Please fill out ⑩a分野（Lab）, ⑩b 指導教授（Supervisor）, ⑩c コース(Course) you would apply.⑩c コース(Course) are as follows. Please tick applicable course. If you tick □ 腫瘍専門医養成コース（□Tumor Training Course）, write the name of sub course as well.

ⅰ）□一般コース（□General course） ⅱ）□ 分子イメージング教育コース（□Molecular Imaging Course ） ⅲ）□ 医学物理士養成コース（□Medical Physicists Training Course） ⅳ）□ 腫瘍専門医養成コース（□Tumor Training Course）

サブコース名（Name of the Sub Course）ⅴ）□ 総合診療研修医コース (□ Comprehensive Medicine Course) ⅵ）□ Network Medicine Course

⑪専門科目試験（Exam Subjects）：When choosing exam subjects, please ask for some help to the supervisor you would like apply for.

⑪a 主科目（Core Subject）, ⑪b 副科目（Elective Subject）Note: If you are an applicant for “screening for working adults”, ⑪b 副科目（Elective Subject）is not

applicable to you, so please leave it blank. ⑫□了承を得た（Whether to obtain a consent to take entrance exam by supervisor you would like to apply

or not.）: If you have already obtained it, please tick □.⑬出願資格（Eligibility）：出願資格（Eligibility）is categorized as following (1)-(3) in this form, so please choose applicable oneand fill it out.

⑬A出願資格 Eligibility(1): 大学卒業(見込み)者（University Graduate or Expectant University Graduate）

Please fill out University name, type of University, faculty, major, date of graduation (expected graduation), and circle the applicable one, graduated or being expected to graduate.

⑬B 出願資格 Eligibility(2): 大学院修了(見込み)者（Those who graduated or is expected to

Graduate from Gradate school) Please fill out name of University and Graduate school, date of graduation (expected graduation), and

circle the applicable one, graduated or being expected to graduate.

⑬C 出願資格 Eligibility(3): 上記(1)(2)以外の者（大学改革支援学位授与機構から学位を授与された 者、入学資格審査に合格した者等）（Those who was qualified his/her eligibility by other than (1) or (2) above. (e.g. Those conferred degree by National Institution for Academic Degrees and Quality Enhancement of Higher Education or those authorized by screening of entrance qualifications) etc)

⑭, ⑮, ⑯ shall be filled out if applicable. ⑭◎就業経験(Work experience): Only applicants for screening for working adults need to fill out in this

section. Please write the name of working place and periods you have worked. ⑮◎医籍登録 (Medical License): If you have, please write Registration Number (Country) and issue

date. ⑯◎初期臨床研修( Junior Resident (clinical trainee)experience) Please circle applicable status of Junior Resident (clinical trainee) experience. ⑯a 終了（Completed） ⑯b 研修中 (In progress) ⑯c 未終了（NOT completed）

Please write “Name of Hospital” and “Periods” that you engaged in as a junior Resident ⑰ 現住所（Present address）: Information in this section will be used when we need to contact you, so please write precisely. ＜Resume> ⑱学歴（Educational Record） Please fill out ⑱a ～⑱c ⑱a 学校名 [正規の修業年限] (Name of school [Standard duration of completion]） ⑱b 入学及び卒業（修了）年月（Date of Enrollment / Graduation (Completion)） ⑱c 在学年数（Duration you belonged to） ⑲職歴（Working Career Record） Please fill out ⑲a ～⑲c ⑲a 勤務先名称 [身分] (Name of working place [Status]) ⑲b 勤務期間（Date of Entrance/ Resignation to/from the working place） ⑲c 在職年数 (Duration of working) Note: ⑱学歴（Educational Record）and ⑲職歴（Working Career Record）shall be described precisely

altogether without blank periods. ⑳賞罰（Reward and Punishment Record）

If any, please fill out. ㉑取得済み学位 (Degree you have already had. (including to be conferred as of 2019 Sep.)) Please write title of the degree in parentheses. ㉒誓約・自署（Pledge）: Please write Date, Name and Signature. Note: Considering difference of the education system in each country, international applicants shall contact Academic affair office in advance to confirm your Eligibility for enrollment. If you do not meet the requirements listed on the admission procedure, you must take “Screening Entrance qualifications” first and pass it before application for Entrance exam.