※ Those with the mark are fields that must be completed.

Name(in alphabet)
学籍番号または受験番号(※不明の場合、0000 と入力してください)Student ID Number or Examinee's Number(※ If unknown, please enter 0000 )
予約番号Reservation Number, if you have.
配偶者の有無Marital Status
生年月日Date of Birth (yyyy/mm/dd)
現住所郵便番号 (※日本ではない場合、郵便番号は000-0000と入力してください)Postal code (※If you do not live in Japan, please set it to 000-0000)
研究室内線Lab Ext
留学プログラム名Study Abroad Program Name
在籍キャンパスEnrolled Campus
現課程の卒業修了見込み年月Expected Date of Graduation/Completion
上級課程への進学予定You wish to continue to..?
奨学金名称Scholarship Name
奨学金月額Scholarship Monthly (¥)
奨学金受給期間Receiving Term
現在の住居費Current Rent Monthly (¥)
入居希望期間Period you wish to live (yyyy/mm/dd)
入居希望日Move-in date and time (yyyy/mm/dd h:mm)
Flight Information
寝具セット購入希望の有無Bedding Set

※You will be needing a bedding set for your bed in your room. (All Titech dormitorys) You can purchase a bedding set (6 items) at a reasonable price from a university partner dealer. (Bedding set flyerPDF)

寝具セット購入を希望しますか / Would you like to purchase a bedding set from our dealer?

誓約事項 Pledge:


Please check below should you agree.

  1. 寮の規則、共同生活のマナーを守り、他の寮生と友好な関係を築くこと。
    To follow the dorm rules and regulations, keep good manner of sharing rooms/facilities, and make a good relationship with other students in the dorm.
  2. 居室や共有スペースを清潔に保つこと。
    To keep your individual room and common spaces/facilities clean.
  3. 寮費は毎月決められた期日に支払うこと。
    To keep the due date for payment.
  4. 寮の規則に反する行為(禁止事項違反、寮費の滞納など)のため退寮を命じられることがあること。
    To accept the withdrawal order from the Student Support Division when acting against rules/regulations or above matters.
  5. 留学または大学が認める特段の理由を除いて、途中退寮および延長は認められないこと。
    To follow the period of residence which is informed when you check in except for studying abroad or special reasons recognized by the university. (neither Change nor Extension)