APPLICATION FORM 2016 (To be filled in by typing) United Nations/Japan Long-term Fellowship Programme Post-graduate study on Nano-Satellite Technologies (PNST) (Deadline for submission: 17:00 24 January 2016) Nominee s full name: (Family name) (First name) (Middle name) (Write your name exactly as it is printed in your passport) Nominee's institution and country: Please include/attach a recent photo here Degree seeking (check one) Master Doctorate The fully completed application form and all other required documents except the referee report forms should be submitted at the web address that is in the confirmation e-mail that you will receive after registering for the programme, in electronic format (.doc or.pdf) no later than 17:00 24 January 2016. The Referee report forms should be sent by email to the Post-graduate study on Nano-Satellite Technologies (PNST) (pnst@langmuir.ele.kyutech.ac.jp) email address by the referees themselves by no later than 17:00 24 January 2016. For submission details see the information note. Selected candidates will be notified by e-mail in March 2016 and should then confirm their acceptance of the offer no later than 5 days after notification. Name, official title and professional relationship of three referees who are familiar with the applicant's work and qualifications: 1. Name Title Relationship 2. 3. Note: Do not fill with handwriting except signature. Please type in with a computer. Office for Outer Space Affairs, United Nations Office at Vienna, Wagramerstrasse 5, 1400 Vienna, Austria Tel. (+43-1) 26060-0, Fax (+43-1) 26060-5830, www.unoosa.org
DEGREE FIELD Aerospace Engineering Mechanical Engineering Control Engineering Electronics and Electrical Engineering Civil Engineering Chemical Engineering Material Science Systems Engineering Information Technology Biomechanics Brain Science Other: Please state the grade point average (GPA) of your study according to the scale and grading system in your institution and specific maximum GPA. During Undergraduate _ / 10 During Master Study _ / 10 RELEVANT COURSES, WORKSHOPS, SEMINARS OR MEETINGS (attended in the last five years.) Location Title of activity Duration (dates) Sponsors TECHNICAL SKILLS & RATE OF ABILITY Please write freely about your technical skills, and _ / 10 your rate of ability. PNST Application Form 2016 2 of 5
STATEMENT OF PURPOSE Name Explain your reasons for applying to participate in this Fellowship Programme at Kyutech. Please include the answer to the following questions; Q1. What is your motivation to participate in this programme and what is your post-degree plan? Q2. How do you plan to participate in your home country s space program? What capacity currently exists in your country? Q3. Tell us briefly what research (or work) you are doing now. Q4. Tell us briefly about your academic background, what you did during Master or undergraduate-degree studies. Q5. What do you want to do as your research work for the Master or Doctor degree? You may use separate sheets of paper (max 1,200 words). PNST Application Form 2016 3 of 5
ABSTRACT OF MASTER or BACHLOR THESIS Name If you have not finished your Master s or Bachelor s degree at the time of application, write a progress report. You may use separate sheets of paper (max 2,000 words). Title of thesis PNST Application Form 2016 4 of 5
CERTIFICATION OF KNOWLEDGE OF ENGLISH Name of candidate: ABILITY TO UNDERSTAND SPEECH Understands without difficulty Understands almost everything Requires frequent repetition ABILITY TO WRITE Writes with ease and accuracy Writes slowly Writes with difficulty Other remarks: ABILITY TO SPEAK Speaks fluently Speaks intelligibly Speaks haltingly ABILITY TO READ Reads fluently Reads slowly Reads with difficulty TOEIC Certificate: YES NO IELTS: YES NO TOEFL Certificate: YES NO Cambridge English (ESOL) YES NO Certification by language examiner. Language tested by (Name) (Title of examiner) (Institution, city, country) Date of examination: Seal of Language Signature of examiner: Institution Note: Final candidates who are selected as MEXT fellowship candidates are requested to submit score of one of the internationally acknowledged English exams to Kyutech by the end of June. CANDIDATE'S CERTIFICATION I hereby certify that the statements that I have made in this application form are true, correct and complete. If selected, I hereby confirm that I will comply with the Terms of Reference of the Programme and I will make myself available for duration of the entire Fellowship. Date: Signature of candidate: PNST Application Form 2016 5 of 5