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JAPAN-EAST ASIA NETWORK OF EXCHANGE FOR STUDENTS

AND YOUTHS (JENESYS) PROGRAMME

ASEAN 10 JOINT PROGRAMME


APPLICATION FORM FOR STUDENT AMBASSADORS

Not for Sale – May be reproduced

AREA TO BE REPRESENTED: LUZON VISAYAS MINDANAO NCR

1. Surname: ____________________________________ 2. Gender: [ M ] [ F ]

First Name: ____________________________________ 3. Height: ______________ Passport-sized photo

Middle Name: __________________4. Weight: _________ 5. Age:_________________

Nickname: ___________ 6. Birthdate: _______________ 7. Birthplace: ___________

8. Residence/Mailing Address: _______________________________________________

9. Years of Stay: _______________ 10. Tel. No. (landline/Area Code):________________

11. Zip Code:______ 12. Email Address: _______________13. Cellphone


No.:_________
_______________________
14. Religion: ________________ 15. Passport Number: __________________________ Pls. Indicate date taken

*Applicant’s email address and cellphone number are mandatory.

16. Father’s Name: Place of Birth: Occupation:


17. Mother’s Name: Place of Birth: Occupation:
18. No. of Brother/s
19. No. of Sister/s
20. Educational Background Name of School/University/Address Year / Course Honors Received

College / University

21. Scholarship Grants Donor Inclusive Dates Honors Received

22. Youth Organization/Youth Serving Organization Affiliations:


Name of Organization Position Years of Membership Accomplishments

23. Special Skills or Talents:

24. Food Restrictions: 25. Allergies

26. Dialect(s) or Foreign Language(s) Spoken:

27. Title of Seminar/Training Course Attended Inclusive Dates No. of Hours Conducted by

28. Character References: [not related to you within the third degree of consanguinity]

Name Occupation Address and Telephone No.

29. How did you know about the program? 30. Have you been a participant of any NYC International Exchange
Program? [ ] No [ ] Yes
Newspaper: _____ Radio: ______

Magazine: _____ TV Ads: ______ If yes, please indicate the Program, year and source of fund

Others [pls. Indicate]: _____________________

Please fill up form legibly


31. Have you rendered voluntary service for the NYC? ? [ ] No [ ] Yes

If yes, please state nature of service and how long

32. Have you availed of any program or scholarship grant offered by the Japanese government? [ ] No [ ] Yes

If yes, please indicate the program and year

33. Are you on a scholarship granted by the Department of Science and Technology (DOST)? [ ] No [ ] Yes

34. Have you attended any seminar, conference or trainings abroad? [ ] No [ ] Yes

If yes, please indicate the program and year


35. Have you been involved with any NYC local program or activity? [ ] No [ ] Yes

If yes, please indicate the program(s) and year


36. Have you ever been convicted of any crime involving moral turpitude? [ ] No [ ] Yes

If yes, please indicate the nature and status


37. Do you have any pending case? [ ] No [ ] Yes

If yes, please indicate the nature and status

CONFORME
I hereby certify upon my honor that all facts and information indicated herein are true and correct to the best of my knowledge. I further declare that
any information given by me that is untrue may constitute a ground for expulsion in the JENESYS Programme and prosecution for perjury.

Further, I subscribe and agree that the National Youth Commission has the sole prerogative to select and nominate the delegates to the JENESYS
Programme, and its decision is final and executory.

IN WITNESS hereof, I am executing and signing this statement voluntarily without compulsion.

_____________________________
Signature

PARENTAL CONSENT

I am the parent/legal guardian of __________________________________________ and he/she has applied in the JENESYS Programme with
my consent. In the event that the National Youth Commission chooses him/her, I am hereby giving him/her permission to travel under the supervision of
the chosen Supervisors of the JENESYS Programme.

_____________________________
Signature
Attested by:

________________________________

*Signed by a witness not a relative by consanguinity/affinity up to the 4th degree civil degree.

QUALIFICATION OF STUDENT AMBASSADORS APPLICATION REQUIREMENTS FOR STUDENT AMBASSADORS

 Filipino, single, must be between 16 to 18 years old, on or  Two (2) copies of the application form and 2 two copies of
before April 1, 2009; JENESYS Entry Form, both with passport sized pictures with white
 Of good moral character; background attached to each form (all original, no scanned pictures)
 With exemplary leadership skills: must be an officer of a youth  Two (2) photocopies of birth certificate (from the National
organization in his/her current or immediate past educational Statistics Office-NSO)
institution or any community (public or private) organization;  An essay which states the applicants’ a)Reasons for applying;
 Must be currently enrolled in a college or university with a b)expectations of the programme; c) if chosen, the preparations the
Graded Weight Average (GWA) of 2.25 or 85% equivalent, with no applicant will undertake prior to departure (maximum of 100 words
failing marks in the preceding semester; per question)
 Physically and mentally fit to travel;  Two (2) copies of resume, not more than three (3) pages
 Must be a first time traveler to Japan and/or must not have been  Two (2) copies of Certificate of Good Moral Character, issued by
a grantee or recipient of any NYC funded international travel or the school, college or university (1 original and 1 photocopy)
Japanese Government grant;  Two (2) copies of the certified copies of the grades (1 original
 Must be knowledgeable of the history, geography, culture and and 1 photocopy)
arts, and the current issues on the Philippines, and fairly  Two (2) copies of Police or NBI clearance (1 original and 1
knowledgeable in those of Japan and other East Asian countries; photocopy)
 Must be an officer or an active member of a youth organization  Completed NYC Volunteer Form
at least one (1) year immediately preceding the date of application;  Certification from school or organization that the applicant is an
 Must be willing to be an active NYC and JICC volunteer after the officer
program to continue to promote the learnings about Japan and the
Japanese culture gained from the JENESYS Programme; * Passport must be valid six (6) months after the date of departure
 Area representation would be based on the place of the school,
college or university enrolled in. * Submit only the required documents

NOTE:
 Deadline for submission of application form is December 15, 2008.
 The National Youth Commission reserves the right and prerogative to exclude applicants who will not meet the minimum requirements of the
Program. Lack or non-compliance of any of the above stated requirements will mean automatic disqualification without notice.
 Mail or hand carry your application to Ms. Marielou A. Chua, National Youth Commission, 4th Flr., Bookman Building, 373 Quezon Avenue,
Quezon City, Tel Nos. 781-1617/781-1152/781-1406/749-9401/749-9404/749-9409/749-9399 locals 113 and 115.
Please fill up the form legibly [pls. Photocopy submit 2 copies]