INTERNATIONAL CHRISTIAN UNIVERSITY

ELIGIBILITY CHECK FORM

Date :
yyyy/mm/dd

Name
Last/family/sur First/given Middle (initial)

Date of Birth Email address

yyyy/mm/dd Please double-check that the email address you entered is correct and valid.
Native
Nationality(ies) Language(s)

When do you plan to (Choose one from the pulldown list)

Desired Student Status
(Choose one from the pulldown list)
enter ICU?
April or September Year https://www.icu.ac.jp/en/admissions/undergraduate/engdoc/categories/

EDUCATIONAL BACKGROUND
ELEMENTARY EDUCATION (e.g. grade school, primary school, etc.)
Location Dates of Attendance Year/Grade Language of
Name of School(s) (City, State/Province & Country) (from Year/Month to Year/Month) (e.g. Y1-Y13) Instruction

(Example) ICU Elementary School Tokyo, Japan 2001/09 - 2007/06 Grade 1-6 English

SECONDARY EDUCATION (e.g. middle school, junior high school, senior high school)
Location Dates of Attendance Year/Grade Language of
Name of School(s) (City, State/Province & Country) (from Year/Month to Year/Month) (e.g. Y1-Y13) Instruction

Certifiate/Diploma
(Expected) Date of Graduation
(To Be Awarded)
(e.g. US High School Diploma) Year/Month/Day
Website address of the high school that you graduated
(or are expected to graduate) from, if available

HIGHER EDUCATION (university or college)

Location Dates of Attendance Language of
Name of School(s) (City, State/Province & Country) (from Year/Month to Year/Month) Instruction

(Expected) Degree Conferred (Expected) Date of Conferred

(e.g. Associate, Bachelor, Master, etc.) Year/Month/Day

EDUCATIONAL CERTIFICATION (SAT, ACT Plus Writing, IB Diploma, GCE A Level, or Other National Exam/Certificate)
https://www.icu.ac.jp/en/admissions/undergraduate/engdoc/edcert/
Have you taken (obtained) / Will you take (obtain) any of the following tests
Yes When did/will the result come out? No
(qualifications)?
- SAT or ACT Plus Writing □ ( ) □
- IB Diploma □ ( ) □
- GCE A Level □ ( ) □

Or have you taken / will you take a national examination or completed a college-
bound program that qualifies you to enter a four-year university in the country/region □ ( ) □
on which your high school curriculum is based?

1/4
 - (If applicable) What is the name of the examination or the program you took (or (in English/alphabet)
are going to take)?
(in a local language, if any)

SPECIAL REMARKS
If you have any notes or additional information, please feel free to leave a comment below.

Thank you for completing this form. ICU gurantees strict confidentiality regarding the information given through this form.

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 INTERNATIONAL CHRISTIAN UNIVERSITY
ELIGIBILITY CHECK FORM
Date : 2022/4/22
yyyy/mm/dd

Name Kokusai Motoko C.

Last/family/sur First/given Middle (initial)

6/15/2002 admissions-center@icu.ac.jp
Date of Birth Email address
yyyy/mm/dd Please double-check that the email address you entered is correct and valid.
Native
Nationality(ies) Japanese, United States Language(s) English

When do you plan to September 2023 Desired Student Status

Transfer (Second-Year-Transfer) Student
enter ICU?
April or September Year https://www.icu.ac.jp/en/admissions/undergraduate/engdoc/categories/

EDUCATIONAL BACKGROUND
ELEMENTARY EDUCATION (e.g. grade school, primary school, etc.)
Location Dates of Attendance Year/Grade Language of
Name of School(s) (City, State/Province & Country) (from Year/Month to Year/Month) (e.g. Y1-Y13) Instruction

(Example) ICU Elementary School Tokyo, Japan 2001/09 - 2007/06 Grade 1-6 English

XXX American Elementary School Tokyo, Japan 2008/09-2012/06 Grade 1-4 English

XXX International School Tokyo, Japan 2012/09-2016/06 Grade 5-8 English

SECONDARY EDUCATION (e.g. middle school, junior high school, senior high school)
Location Dates of Attendance Year/Grade Language of
Name of School(s) (City, State/Province & Country) (from Year/Month to Year/Month) (e.g. Y1-Y13) Instruction

XXX High School New York, US 2016/09-2019/06 Grade 9-11 English

XXX International School Tokyo, Japan 2019/09-2020/06 Grade 12 English

Certifiate/Diploma US High School Diploma 6/1/2020

(Expected) Date of Graduation
(To Be Awarded)
(e.g. US High School Diploma) Year/Month/Day
Website address of the high school that you graduated
(or are expected to graduate) from, if available https://icu-h.ed.jp/

HIGHER EDUCATION (university or college)

Location Dates of Attendance Language of
Name of School(s) (City, State/Province & Country) (from Year/Month to Year/Month) Instruction
San Diego, California,
University of XXX, XXX 2020/09-2023/06 English
United States

Bachelor's Degree 6/1/2024

(Expected) Degree Conferred (Expected) Date of Conferred
(e.g. Associate, Bachelor, Master, etc.) Year/Month/Day

EDUCATIONAL CERTIFICATION (SAT, ACT Plus Writing, IB Diploma, GCE A Level, or Other National Exam/Certificate)
https://www.icu.ac.jp/en/admissions/undergraduate/engdoc/edcert/
Have you taken (obtained) / Will you take (obtain) any of the following tests
Yes When did/will the result come out? No
(qualifications)?
- SAT or ACT Plus Writing X ( 6/15/2022 □
- IB Diploma □ ( □
- GCE A Level □ ( □

Or have you taken / will you take a national examination or completed a college-
bound program that qualifies you to enter a four-year university in the country/region □ ( □
on which your high school curriculum is based?

3/4
 - (If applicable) What is the name of the examination or the program you took (or (in English/alphabet)
are going to take)?
(in a local language, if any)

SPECIAL REMARKS
If you have any notes or additional information, please feel free to leave a comment below.

Thank you for completing this form. ICU gurantees strict confidentiality regarding the information given through this form.

4/4