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  □M  □F

□Buddhist □Hindu

□Christian (□Roman Catholic □Protestant □Other)   □Muslim □Others (            )

Marital Status Number

  □Single  □Married
□ 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)

e. 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. Academic Details Name of School or Organization * Please fill in the form in BLOCK LETTERS in English. Other Allergies and □none Restriction □dogs □cats □house dust □others ( ) 3.Health Condition Blood Type □A   □B   □O    □AB □Good □Previously diagnosed disease: ( Health Condition * Please fill in the form in BLOCK LETTERS in English.2.)  □chronic heart disease (congenital heart disease.) □immunodeficiency state (T cell immunodeficiency etc.2(April 9.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.g. □don't-know ) □Having Chronic disease: □chronic lung disease (asthma. 2013) . Location: (city. 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. chronic obstructive lung disease etc.

Personal Activities Activities Sports/Clubs Hobbies * Please fill in the form in BLOCK LETTERS in English.0. Signature: Date: / / (Day/Month/Year) Japan International Cooperation Center EF ver. what was the purpose of the visit and where did you visit? Yes No * Please fill in the form in BLOCK LETTERS in English. If Yes. 6. Period of Involvement Academic Awards (if any) 5. Other Information Have you ever been to Japan before? If Yes. Declaration I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge. 2013) .4.2(April 9. any candidates who have participated in JENESYS 2. Please describe your expectation by participating in this programme. Expectations * Please fill in the form in BLOCK LETTERS in English. When? *In principle. 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 before are not allowed to take part again.

Sign up to vote on this title
UsefulNot useful