WHAT TO DO FOR YOUR APPLICATION

CHECKLIST

If you meet the criteria of eligibility listed above, you can apply for the program. In order to complete your
application, all of the following documents must be arrived by 17:00 (JST) 30th June 2021 to the email address
below.
ADB-JSP administrative office in school of International Health, The University of Tokyo
[email protected], [email protected]
※Note that the deadline is absolute and materials received after this specified deadline will not be accepted.
Please use this checklist to make sure that all the necessary documents are ready to be sent.

Name: (Male / Female)

(Family name) (First name) (Middle name)

Application for: □ Master course

Please tick ☑ for accompanying documents in the following and attach this sheet with the documents.

1. □ Form #1 Application form for admission

2. □ Form #2 Self-evaluation form

3. □ Form #3 Health certificate completed by a registered medical doctor

4. □ Photograph (3 cm×4 cm) taken within the past six months

5.□ Copy of passport

6. □ Academic Records such as copy of Diploma/Graduate Certificate and Transcripts.

7. □ Certificate of Employment and Compensation (issued by the company with company’s

letterhead/logo and signed by authorize signatory).
The certificate must state the following details:
a. Start date of employment;
b. End date of employment;
Example:
1. January 2016 to December 2017
2. January 2016 to Present (if currently working/connected to the company)
c. Monthly or Annual Income
(Note: if in local currency, fill-out and submit the income conversation to USD form provided by
ADB-JSP)
Note: if the present job is less than 2 years, submit also the certificate of employment from the previous
company.

8. □ Certificate of Family Income issued by the company (with company’s letterhead/logo):

a. Parents’ Annual/Monthly Income if applicant is single;
b. Spouse’s Annual/Monthly Income if applicant is married
(Note: if in local currency, fill-out and submit the income conversation to USD form provided by
ADB-JSP)
c. If status is unemployed, retired or deceased, an authenticated supporting document must be submitted
(e.g. issued by the local government)

9. □ Score sheet of TOEFL (Test of English as a Foreign Language), TOEIC (Test of English for
international Communication) or IELTS (International English Language Testing System) described on
Form #2. A candidate should submit the score. This is a must.
10. □ A copy of the most important research paper, report, or publication authored by the applicant, if any.

11. □ Information Sheet

12. □ Two Evaluation Reports (Form #4&#5 ) are preferably prepared and signed by a dean, a
chairperson of the department or a professor of the university you attend or attended most recently. The
report should be submitted to the ADB-JSP administrative office from the recommender by using a
designated link. The link information will be given to the applicant after all application documents are
confirmed.

WHO WILL WRITE AND SEND THE EVALUATION REPORTS?

1. 2.

Note that all documents submitted will not be returned.

 Form #1 (1
APPLICATION FOR ADMISSION

ADB-JSP MASTER PROGRAM, SCHOOL OF INTERNATIONAL

HEALTH, THE UNIVERSITY OF TOKYO

Please complete the form in block letters or type, so that your information can be easily read.

1. Name: (Male/Female)

(Family name) (First name) (Middle name)

2. Date of birth:

3. Nationality:

4. Marital status: (Single/Married)

5. Family members residing in Japan: (Yes/No)(relationship )

6. Current student or employment status (with name of university or employer):

7. Current mailing address:

Telephone number: Fax number:

E-mail:

Permanent home address:

8. Academic record(s):

(a) Bachelor: (Degree)

(Major)

(Dates) From to (Day/Month/Year)

(Day/Month/Year)
(Name and address of institution)
 Form #1 (2

(b) If you have received other Bachelor, Masters or Doctoral degrees, please indicate
the details below.

9. Total period of education (from elementary school to last institution of education)

Years

10. Please indicate here one of the Departments in School of International Health, the University
of Tokyo, in which you wish to undertake your research. (Please consult with GUIDE TO
SCHOOL OF INTERNATIONAL HEALTH, THE UNIVERSITY OF TOKYO.)

11. Please describe your research proposal during the course when you are admitted to the ADB-
JSP Program, using less than 2 pages of sheets attached.
 Form #1 (3

12. Explain the title and contents of your research proposal

Research title:

Contents:
 Form #1 (4

(continued)
 Form #2
SELF-EVALUATION OF ACADEMIC LEVEL

ADB-JSP PROGRAM IN SCHOOL OF INTERNATIONAL

HEALTH THE UNIVERSITY OF TOKYO

Name of applicant:

1. English language proficiency (Mark one of the following five categories):

Equivalent to native English speaker Excellent

Good Usual
Poor

2. Most recent score of TOEFL, TOEIC or IELTS.

TOEFL: (score) (date)

TOEIC: (score) (date)

IELTS: (score) (date)

3. State your scholastic abilities as clear as possible, and if you have received awards or
scholarships, please specify them.
 Form #3
CERTIFICATE OF HEALTH (to be completed by examining physician)
Please print or type in English.

Name: ( Mr./ Ms.)

Date of birth:

1. Physical examination

Height: Body weight: Blood pressure: /

Pulse: (regular/ irregular)

Visual acuity (eyesight): (R) (L)

(with glasses or contact lenses): (R) (L)

2. Describe the results of X-ray examinations of applicant's chest (X-rays taken more than 6 months
prior to the certification are NOT valid).
Date:
Film No.:
Cardiomegaly: ( + ± -)

3. Past history: please indicate with [+] for YES or[-]for NO.

Tuberculosis: Kidney disease:

Malaria: Cardiac disease:
Rheumatic fever: Diabetes:
Epilepsy: Allergy:
Other communicable diseases (if YES, specify):

4. Please describe your impressions of the patient.

(a) Is the applicant emotionally stable?

(b) Does the applicant appear to have a normal behavior pattern?

Physician's name in print:

Office/institution (Name and address):

Date: Signature:
CONFIDENTIAL EVALUATION REPORT ON APPLICANT FOR ADB-JSP PROGRAM AT THE
SCHOOL OF INTERNATIONAL HEALTH, THE UNIVERSITY OF TOKYO Form #4

Name of applicant:
(Mr./Ms.)
Family name First name Middle name

To the Recommender:

The person named above is applying for admission to the Asian Development Bank- Japan Scholarship Program
(ADB-JSP) in School of International Health, The University of Tokyo. We are grateful if you would let us know
your confidential opinion of the applicant's academic abilities and potential for research, together with some
comments on his/her personality, in the following form.
This report is confidential. Therefore, it should be sealed up in the envelope. Thank you in advance for your kind
cooperation.

1. Please rate the applicant's academic abilities. Tick either one in the following box.

Outstanding (Highest 10%) □

Good (Next highest 15%) □
Above average (Next 15%) □
Average or below (Low 60%) □

2. Please describe the applicant's qualification including reasons for considering him/her for
the program, together with some comments on his/her personality on the back side of this
sheet.

Recommender's name:

Current position:

Date: Signature:
CONFIDENTIAL EVALUATION REPORT ON APPLICANT FOR ADB-JSP PROGRAM AT THE
SCHOOL OF INTERNATIONAL HEALTH, THE UNIVERSITY OF TOKYO Form #5

Name of applicant:
(Mr./Ms.)
Family name First name Middle name

To the Recommender:

The person named above is applying for admission to the Asian Development Bank- Japan Scholarship Program
(ADB-JSP) in School of International Health, The University of Tokyo. We are grateful if you would let us know
your confidential opinion of the applicant's academic abilities and potential for research, together with some
comments on his/her personality, in the following form.
This report is confidential. Therefore, it should be sealed up in the envelope. Thank you in advance for your kind
cooperation.

3. Please rate the applicant's academic abilities. Tick either one in the following box.

Outstanding (Highest 10%) □

Good (Next highest 15%) □
Above average (Next 15%) □
Average or below (Low 60%) □

4. Please describe the applicant's qualification including reasons for considering him/her for
the program, together with some comments on his/her personality on the back side of this
sheet.

Recommender's name:

Current position:

Date: Signature: