別紙様式（第３条関係）

  Date:                       
 Day/Month/Year      

Application Form for SDG Professional Course Scholarship 
at Nagaoka University of Technology

To the President of Nagaoka University of Technology:

　I hereby apply for SDG Professional Course Scholarship at Nagaoka University of Technology. Furthermore, I declare that I am not receiving or scheduled to receive the Japanese Government (Monbukagakusho) Scholarship or any scholarship from any organization including an organization of my home country government.

Applicant Information (Write your name exactly as it appears on your passport)
Name 		
Program	□	Master’s Program　　　　□ Doctoral Program	
Major		
Signature		

Reason for the Application (It is required to be written by the Applicant.)