Entry Form for JENESYS 2.

0
Traditional Culture / Heritage / Art (___ Batch) 1. Personal Information
Photo (taken within 3 months) Please write your name on the back of your photo.
Name Given name (English)

Reg.No.

* Please fill in the form in BLOCK LETTERS in English. Full Name (Exactly the same as your passport)

Family Name (English) Middle Name (if any)(English)

Full Name (in Mother language)

Nickname (Please specify

the name you would like to be called)

Date of Birth Nationality Religion Mother Tongue

Day/Month/Year

Age (as of the day of the flight to Japan) Sex MF

Buddhist Hindu

Christian (Roman Catholic Protestant Other) Muslim Others (

Marital Status Number

SingleMarried
Diplomat (Month) Official (Year)

Type of Passport Private Date of Expiry (Day)

Passport**

Date of Issue (Day) Address

(Month)

(Year)

Current Address Tel Mobile Full Name Contact Person in Emergency

*It shall be your parent. *If you live with him/her, please leave address blank.

Fax E-mail Relationship

Address

Tel Mobile Profession/Occupation

Fax E-mail

*If you do not have Name Phone Number E-mail phone at your current address, please write contact person and number. **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.

Japan International Cooperation Center EF ver.2(April 9, 2013)

2.Health Condition
Blood Type A B O AB Good Previously diagnosed disease: ( Health Condition

* Please fill in the form in BLOCK LETTERS in English.

don't-know

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 gravis others ( ) Not taking any medicines Taking medicines regularlly (Specified Yes No none pork none beef chicken mutton/lamb shrimp crab shellfish ) mutton/lamb shrimp crab shellfish ) fish egg pork others ( chicken )

Medicine

Pregnancy

Food Allergies (only for physical reason) Food Restriction (for religion or custom reason)

beef

fish egg

others (

*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

Other Allergies and none Restriction dogs

cats

house dust

others (

3. Academic Details
Name of School or Organization

* Please fill in the form in BLOCK LETTERS in English.

Location: (city,province)

Information of your School/Organization

Field of study(for university student only) Grade/school year (for student)

as of the day of the flight to Japan

Tel: Fax:

Title (for supervisor only)

English Proficiency
certificated score (if any, e.g. TOEFL)

Level of English
Speaking: Good Language Writing : Good Reading : Good Other Language Fair Fair Fair Poor Poor Poor

Level of Japanese
Speaking: Good Writing : Good Reading : Good Fair Fair Fair Poor Poor Poor

Japanese Year or Month learning experience

Japan International Cooperation Center EF ver.2(April 9, 2013)

4. Personal Activities
Activities Sports/Clubs Hobbies

* Please fill in the form in BLOCK LETTERS in English.

Period of Involvement

Academic Awards
(if any)

5. Expectations

* Please fill in the form in BLOCK LETTERS in English.

Please describe your expectation by participating in this programme.

6. Other Information
Have you ever been to Japan before? If Yes, what was the purpose of the visit and where did you visit?
Yes No

* Please fill in the form in BLOCK LETTERS in Englis.

If Yes, When?

*In principle, any candidates who have participated in JENESYS 2.0 before are not allowed to take part again.

Declaration I 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 JENESYS2.0 I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2.0. Signature: Date: / / (Day/Month/Year)

Japan International Cooperation Center EF ver.2(April 9, 2013)