Download - Entry Form(1st Batch) (1)
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Japan International Cooperation Center EF ver.2(April 9, 2013)
1. Personal Information * Please fill in the form in BLOCK LETTERS in English.
NameFull Name (Exactly the same as your passport)English
Full Name (in Mother language)
Date of Birth Day/Month/Year
Nationality
Religion
Mother Tongue Marital Status
Number Type of Passport
Date of Issue Date of Expiry (Day) (Month) (Year) (Day) (Month) (Year)
Facebook Twitter Instagram
Entry Form for JENESYS2015India 1st Batch: Science and Technology
Given name (English) Family Name (English)
Buddhist Christian (Roman Catholic Protestant Other) Not ApplicableHindu Muslim Others (
Passport** Private Diplomat Official
SNS User Name*on a voluntary basis
MOFA and JICE might use your postings related to JENESYS through above mentioned SNS in our reports and website, that will possibly be open to the public.
Current Address
Address
Tel Fax Mobile E-mail
Contact Person in case of Emergency
*It shall be your parent.*If you live with him/her,
please leave address blank.
Full Name
Photo
(taken within 3 months)
Please write your
name on the back of your
photo.
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Japan International Cooperation Center EF ver.2(April 9, 2013)
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
Contact Person in case of Emergency
*It shall be your parent.*If you live with him/her,
please leave address blank.
Address
Tel Fax Mobile E-mail Profession/Occupation
*If you do not have a phone at your current address, please write a contact person and
number.
Name Phone Number
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Japan International Cooperation Center EF ver.2(April 9, 2013)
2.Health Condition * Please fill in the form in BLOCK LETTERS in English.Blood Type
Health Condition
Medicine
Pregnancy
*Please be noted that the meals provided in the programme cannot meet all the requests from the participa
Smoking Habit
3. Academic Details/Organization * Please fill in the form in BLOCK LETTERS in English.Name of School or Organization
Field of study or Department
Title (for supervisor only)
Language
Level of English Level of Japanese
A B O AB I don't-knowGood
Previously diagnosed serious disease:( : fully recovered / under treatment) Having Chronic disease: Chronic lung disease (asthma, chronic obstructive lung disease etc.) Immunodeficiency state (T cell immunodeficiency etc.) Chronic heart disease (congenital heart disease, coronary artery disease etc.)Metabolic disease (diabetes) renal dysfunction obesity myasthenia gravisOthers ( )
Not taking any medicine
Taking medicine regularly (Specified )
Yes No
Food Allergies(only for physical reason)
none
pork beef chicken mutton/lamb shrimp crab shellfish
fish egg others ( )
Food Restriction (for religion or custom reason)
none
pork beef chicken mutton/lamb shrimp crab shellfish
fish egg others ( )
Other Allergies and Restriction
none
dogs cats house dust others ( )Yes No
Smoking is prohibitted by Japanese Law in case you are under the age of 20.JICE make use of this information only for the homestay arrangement.
Information of your School/Organization
Write your Organization if you are
not student Grade/school year (for student)as of the day of the flight to Japan
English Proficiency certificated score (if any, e.g. TOEFL)
Speaking Good Fair Poor Speaking Good Fair Poor
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Japan International Cooperation Center EF ver.2(April 9, 2013)
Language
Other Language
Writing Good Fair Poor Writing Good Fair Poor
Reading Good Fair Poor Reading Good Fair PoorJapanese learning
experience
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Japan International Cooperation Center EF ver.2(April 9, 2013)
4. Personal Activities * Please fill in the form in BLOCK LETTERS in English.Activities
Sports/Clubs
Hobbies
5. Expectations * Please fill in the form in BLOCK LETTERS in English.
6. Other InformationHave you ever been to Japan before? Yes
If Yes,your visit is financed by Yourself
Academic Awards(if any)
Please describe your expectation by
participating in this programme.
* Please fill in the form in BLOCK LETTERS in English.
Japanese government, JICA, Japan Foundation,
JOCA
If Yes, when, what was the purpose of the visit and where did you visit?
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Japan International Cooperation Center EF ver.2(April 9, 2013)
DeclarationI hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.
Signature: Date: / / (Day/Month/Year)
Agreement of the Application Guidelines for JENESYS2015.
I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2015. Signature: Date: / / (Day/Month/Year)
Parent/guardian (if applicant is under 18 years of age) :
Signature: Date: / / (Day/Month/Year)
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Japan International Cooperation Center EF ver.2(April 9, 2013)
Reg.No.
* Please fill in the form in BLOCK LETTERS in English.Full Name (Exactly the same as your passport)
Sex
Type of Passport
Date of Expiry (Day) (Month) (Year)
Instagram others
Entry Form for JENESYS2015India 1st Batch: Science and Technology
Middle Name (if any)(English)
Nickname (Please specify the name you would like to be called)
Age (as of the day of the flight to
Japan)
MF
Other) Not Applicable
SingleMarried
Private Diplomat Official
MOFA and JICE might use your postings related to JENESYS through above mentioned SNS in our reports and
Relationship
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Japan International Cooperation Center EF ver.2(April 9, 2013)
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
E-mail
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Japan International Cooperation Center EF ver.2(April 9, 2013)
* Please fill in the form in BLOCK LETTERS in English.
*Please be noted that the meals provided in the programme cannot meet all the requests from the participa
* Please fill in the form in BLOCK LETTERS in English.Location: (city,province)
Tel:
Fax:
Level of Japanese
fully recovered / under treatment)
Chronic lung disease (asthma, chronic obstructive lung disease etc.)
Chronic heart disease (congenital heart disease, coronary artery disease etc.)obesity myasthenia gravis
)
crab shellfish
others ( )
crab shellfish
( )
others ( )
Smoking is prohibitted by Japanese Law in case you are under the age of 20.
Speaking Good Fair Poor
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Japan International Cooperation Center EF ver.2(April 9, 2013)
Year or Month
Writing Good Fair Poor
Reading Good Fair Poor
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Japan International Cooperation Center EF ver.2(April 9, 2013)
* Please fill in the form in BLOCK LETTERS in English.
Activities
* Please fill in the form in BLOCK LETTERS in English.
No
Period of Involvement
* Please fill in the form in BLOCK LETTERS in English.
Others(
)
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Japan International Cooperation Center EF ver.2(April 9, 2013)
I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.
/ / (Day/Month/Year)
I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2015.
/ / (Day/Month/Year)
/ / (Day/Month/Year)
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EF ver.2(April 9, 2013)
Entry Form for JENESYS2015
1. Personal Information * Please fill in the form in BLOCK LETTERS.
NameFull Name (Exactly the same as your passport)English
TARO YAMADA
TARO YAMADA
Full Name (in Mother language)
Date of Birth
Nationality Japanese
Religion
Mother Tongue Japanese Marital Status
Number Type of PassportTG123456
Date of Issue Date of Expiry
Facebook Twitter Instagram
yamada taichi taichi-yamada
kita shinjyuku 1-2-4, Tokyo, Japan 123-0045
(Japan
Given name (English) Family Name (English)
Day/Month/Year 25/12/1989
Buddhist Christian (Roman Catholic Protestant Other) Hindu Muslim Others (
Passport** Private Diplomat Official
(Day) (Month) (Year) 3 3 2010
(Day) (Month) (Year) 3 3 2010
SNS User Name*on a voluntary basis
MOFA and JICE might use your postings related to JENESYS through above mentioned SNS in our reports and website, that will possibly be open to the public.
Current Address Tel 03-999-9999 Fax 03-456-9999Mobile 030-456-9999 E-mail [email protected]
Contact Person in Emergency
*It shall be your parent.*If you live with him/her,
please leave address blank.
Full Name TAICHI YAMADA
Photo
(taken within 3 months)
Please write your
name on the back of your
photo.
-
EF ver.2(April 9, 2013)
Profession/Occupation: Singer
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
Contact Person in Emergency
*It shall be your parent.*If you live with him/her,
please leave address blank.
Full Name TAICHI YAMADA
Address minami shinjuku 5-6-7, Tokyo, Japan 123-0099
Tel 03-456-7890 Fax 03-456-7890Mobile 03-456-7890 E-mail [email protected]
*If you do not have phone at your current address,
please write contact person and number.
Name Phone Number
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EF ver.2(April 9, 2013)
2.Health ConditionBlood Type
Health Condition
Medicine
Pregnancy
*Please be noted that the meals provided in the programme cannot meet all the requests from the participa
Smoking Habit
3. Academic DetailsName of School or Organization
Shinjuku high schoolField of study(for university student only)
3rd
A B O AB don't-knowGood Previously diagnosed serious disease:( : fully recovered / under treatment) Having Chronic disease: chronic lung disease (asthma, chronic obstructive lung disease etc.) immunodeficiency state (T cell immunodeficiency etc.) chronic heart disease (congenital heart disease, coronary artery disease etc.)metabolic disease (diabetes) renal dysfunction obesity myasthenia gravisothers ( )
Not taking any medicines
Taking medicines regularly (Specified )
Yes No
Food Allergies(only for physical reason)
none
pork beef chicken mutton/lamb shrimp crab shellfish
fish egg others ( )
Food Restriction (for religion or custom reason)
none
pork beef chicken mutton/lamb shrimp crab shellfish
fish egg others ( )
Other Allergies and Restriction
none
dogs cats house dust others ( )Yes No
Smoking is prohibitted by Japanese Law in case you are under the age of 20.JICE make use of this information only for the homestay arrangement.
Information of your School/Organization
Grade/school year (for student)as of the day of the flight to Japan
-
EF ver.2(April 9, 2013)
Title (for supervisor only)
Language
TOEFL 250
Level of English Level of Japanese
Other Language
Information of your School/Organization
English Proficiency certificated score (if any, e.g. TOEFL)
Speaking Good Fair Poor Speaking Good Fair Poor
Writing Good Fair Poor Writing Good Fair Poor
Reading Good Fair Poor Reading Good Fair PoorJapanese learning
experience
-
EF ver.2(April 9, 2013)
4. Personal ActivitiesActivities
Sports/Clubs skiHobbies drawing the cartoon
first prize in English contest
5. Expectations
6. Other Information*Applicants who have participated in the programme organized by the Japanese Government before are not allowed to take part again.
Have you ever been to Japan before? Yes
If Yes,your visit is financed by Yourself
Academic Awards(if any)
Please describe your expectation by
participating in this programme.
Japanese government, JICA, Japan Foundation,
JOCA
If Yes, when, what was the purpose of the visit and where did you visit?
-
EF ver.2(April 9, 2013)
DeclarationI hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.
Signature: Date: 24 / 10 / 2012 (Day/Month/Year)
Agreement of the Application Guidelines for JENESYS2015I hereby agree to the qualifications of health conditions and the use of my personal information for the purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2015.
Signature: Date: 24 / 10 / 2012 (Day/Month/Year)
Parent/guardian (if applicant is under 18 years of age) :
Signature: Date: 24 / 10 / 2012 (Day/Month/Year)
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EF ver.2(April 9, 2013)
Reg.No.
* Please fill in the form in BLOCK LETTERS.Full Name (Exactly the same as your passport)
TARO YAMADA
DAVID
TARO
18
Sex
Type of Passport
Date of Expiry
Instagram others
kita shinjyuku 1-2-4, Tokyo, Japan 123-0045
Middle Name (if any)(English)
Nickname (Please specify the name you would like to be called)
Age (as of the day of the flight to
Japan)
MF
Other)
SingleMarried
Private Diplomat Official
(Day) (Month) (Year) 3 3 2010
MOFA and JICE might use your postings related to JENESYS through above mentioned SNS in our reports and
03-456-9999 [email protected]
Relationship father
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EF ver.2(April 9, 2013)
Singer
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
Relationship father
03-456-7890
E-mail
-
EF ver.2(April 9, 2013)
*Please be noted that the meals provided in the programme cannot meet all the requests from the participa
Location (city,province)Tokyo
fully recovered / under treatment)
chronic lung disease (asthma, chronic obstructive lung disease etc.)
chronic heart disease (congenital heart disease, coronary artery disease etc.)obesity myasthenia gravis
)
crab shellfish
others ( )
crab shellfish
( )
others ( )
Smoking is prohibitted by Japanese Law in case you are under the age of 20.
Tel: 03-567-1111
-
EF ver.2(April 9, 2013)
TOEFL 250
Level of Japanese
Year or Month
Fax: 03-567-1112
Speaking Good Fair Poor
Writing Good Fair Poor
Reading Good Fair Poor
-
EF ver.2(April 9, 2013)
Activities
ski 2 years
drawing the cartoon 5 months
first prize in English contest
*Applicants who have participated in the programme organized by the Japanese Government before are not allowed to take part again.
No
Period of Involvement
Others(
)
-
EF ver.2(April 9, 2013)
I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.
24 / 10 / 2012 (Day/Month/Year)
I hereby agree to the qualifications of health conditions and the use of my personal information for the purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2015.
24 / 10 / 2012 (Day/Month/Year)
24 / 10 / 2012 (Day/Month/Year)
FormSample