My last/family name is:

My first name is:

The name I want to be called by professors in class is:

My dormitory and room number are:

My phone number is:

My post office box number is:

What is your major at TIU? (for example: International Relations)

(Check all that are true.) I want to learn English to:

___ improve my status in Japan
___ impress my friends
___ make my parents happy
___ communicate with friends who don't speak my native language
___ get a job
___ work in an international environment (business, tourism, etc.)
___ travel to other countries
___ talk to people all over the world
___ read in English for pleasure
___ listen to music with English words
___ succeed in my TIUA and Willamette classes
___ study at a university in an English-speaking country
___ use the Internet ordo other activities with computers
___ increase my ability to think; to challenge myself mentally
___ other (please explain): _____________________
___ other (please explain): _____________________
___ other (please explain): _____________________

My personal interests, hobbies and free-time activities in Japan are:

___ I can / ___ I cannot sing or play a musical instrument: _____________________

___ I am / ___ am not a photographer

___ I am / ___ am not an artist

Language knowledge

Besides English and Japanese, I also speak these languages well: ___________________________

Besides English and Japanese, I have studied these languages: ___________________________

I have spent more than two weeks in these countries? (Use the back if necessary.)

Country:
What did you do and how long did you stay?

Country:
What did you do and how long did you stay?

Outside of class at TIUA, I think I will study and do homework this number of hours each week (circle one):

The two main reasons I came to TIUA are:

1.

 

 

 

2.

Your health: Vision (the ability to see)

___ I have no problems seeing the blackboard and reading. My eyesight is excellent or I have glasses that give me excellent vision.

___ I do have problems seeing the blackboard or reading. I need glasses or better glasses, or I have some other problem with my eyes.

 

I think it would help you to know this other additional information about me: