Nagoya University Program For Academic Exchange (nupace)

2021

Application Form for School Special Audit Student,

School of Engineering

Affix photograph

(3 cm x 4 cm) taken within last three months.
The photograph should be taken directly from the front, and show the applicant’s head and shoulders. No headwear is permitted.

* TYPE or PRINT all information in Roman letters and Arabic numerals.

1. 
   Name: Husanov Asliddin ( ) ( )
   

family name　 Chinese character(s)　 given (including middle) name(s) Chinese character(s)

2. 
   Sex: Male　　 3. Date of birth: 2002 / 08 / 25
   

year month day

4. 
   Country of citizenship: Uzbekistan
   

5. 
   Mailing address for all admission correspondence: Kashkadarya region, Kitab district, Yangi qishloq village
   

Tel.#: [phone] e-mail: [e-mail]

6. 
   Current university & faculty/department: 　　　 　　　
   

　　 　　　　

7. 
   Research theme at Nagoya University: 　　　　　　　　　　　　　　　　　
   
8. 
   Prospective affiliation Supervisor and Department at School of Engineering, Nagoya University
   

Department : 　　　　　　　 　　　　

Supervisor: 　　　　　　　　　　　　　

7. 
   Planned period of enrolment at Nagoya University.
   

From 01(day.) Oct (mo.) 2021(yr.) to 08(day.) Feb(mo.) 2021(yr.)

7. 
   Specify your intended period of residence in Japan, taking into account academic requirements at your home institution (semester dates, summer school, graduation date, etc.):
   

From (day.) (mo.) (yr.) to (day.) (mo.) (yr.)

11. Using a separate A4-sized paper, make the curriculum vitae which wrote an employment record and educational background.
I, the undersigned, certify that the above statements are true and accurate.

Applicant's signature: Date: