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Reg.No.

Entry Form for JENESYS 2015


Peace Building commemorating 70 years of the end of World War II

1. Personal Information

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


Full Name (Exactly the same as your passport)

Name

BHASKORO

ABDILLAH MUTHOHAR

Given name (English)

Family Name (English)

BHASKORO

MUTHOHAR

the name you would like to be called)

BHASKORO ABDILLAH MUTHOHAR

Mother Tongue

Age

(as of the day


of the flight to
Japan)

INDONESIAN
Buddhist
Hindu

19
MF

Sex

Christian (Roman Catholic Protestant Other)


Muslim
Others (

INDONESIAN LANGUANGE

Marital Status

A 5276614
Date of Issue
(08)

SingleMarried

Type of Passport

Number
Passport**

IBAS

2/12/1996

Nationality
Religion

ABDILLAH
Nickname (Please specify

Full Name (in Mother language)

Date of Birth

Middle Name (if any)(English)

(05)

Private
(2015)

Diplomat

Date of Expiry
(08)

(05)

Official
(2018)

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

Current Address

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

Address
JALAN BANGAU SAKTI NO.8 KEL. SIMPANG BARU, KEC. TAMPAN, KOTA PEKANBARU, RIAU
Tel : -

Fax

Mobile : +628 228 441 2435


Full Name
AHMAD ZAINUDDIN

E-mail : bhaskoro.jr@gmail.com
Relationship :
PARENTS

Address
JALAN TUNAS MUDA NO. 46, KEL. BUKIT DATUK KEC. DUMAI SELATAN, KOTA DUMAI, RIAU
Tel

Fax

Mobile : +628 137 859 1000

E-mail

Profession/Occupation
*If you do not have phone Name

WORKER
Phone Number

E-mail

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

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

A B O AB

don't-know

Good
Previously diagnosed disease:
(
Health Condition

Medicine

Pregnancy

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
Food Allergies
pork beef chicken
(only for physical reason)
fish egg others (

mutton/lamb

shrimp

crab shellfish
)

none
Food Restriction
(for religion or
custom reason)

pork

beef

fish egg

chicken

mutton/lamb

others (

shrimp crab shellfish


)

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

Other Allergies and none


Restriction
dogs

3. Academic Details

cats

house dust

others (

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

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

Name of School or Organization


RIAU UNIVERSITY
Information of your
School/Organization

PEKANBARU, RIAU

Field of study(for university student only)


CHEMICAL ENGINEERING
Grade/school year (for student)
as of the day of the flight to Japan

Title (for supervisor only)


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

Level of English
Language

Location: (city,province)

Tel: 0761-63272
Fax:
460

Level of Japanese

Speaking: Good

Fair

Poor

Speaking: Good

Fair

Poor

Writing : Good

Fair

Poor

Writing : Good

Fair

Poor

Reading : Good

Fair

Poor

Reading : Good

Fair

Poor

Other Language

Japanese Year or Month


learning
experience

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

4. Personal Activities

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

Period of
Involvement

Activities

Sports/Clubs
1. STUDENTS ASSOCIATION OF CHEMICAL ENGINEERING OF RIAU UNIVERSITY,
SCIENCE FORUM DIVITION
2. DARUL HIJRAH ISLAMIC STUDENT ASSOCIATION, PUBLIC RELATIONS

2014-2015
Hobbies

READING BOOK, WRITING, AND COOKING

Academic Awards

1. THIRD WINNER OF PKM-P HIMATEKI RIAU UNIVERSITY


2. FINALIST NATIONAL YOUTH SCI-TECH PAPER COMPETITION

(if any)

2014

2014-2015

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

5. Expectations

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

JENESYS was created by Prime Minister of Japan, Mr. Abe Shinzo at Second East Asia Summit in 2007. This
programme aims to foster awareness of youth people, the next generation, who will have an important role in
the development of East Asia Country.
War and chaos is human nature, planted deep in our memory fragment that sealed in our dna. Even since both
of son of adam and eve killed each other for their personal interest.
Thousands even millions war has been declared by humans, that bring nothing except losses, sadness, and
tears for everyone who involved in.
Wether
humans
deserve
to
lived
like
that? Lived in greed, wrath, and lust to dominating each other. NO. It is
Please describe your
time to break that chains and we as youth people, the next generation, together have a power to stop it. "I know
expectation by
not with what weapons World War III will be fought, but World War IV will be fought with sticks and stones" participating in this
Albert Einstein

programme.

I believe this programme will inspired many peoples, especially youths in East Asian Country to keep maintain
peace in this world. Not only tell that war is bring nothing except destruction for everyone but also to invites
youth to help each others even they have different skin, different colour, different cultures, and different country
to make the world unite as one in peace.
I believe, I have chance to be choosen in this programme because I have a will. A will to make the world as a
better place also with this programme I hope I can learn more about japanese culture that always inspired my
life everyday.

6. Other Information
Have you ever been to Japan before?
If Yes, what was the purpose of the visit
and where did you visit?

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

Yes

No

If Yes, When

Educational Trip

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

Passport Scan

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

Declaration

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

Entry Form for JENESYS 2.0


(Japan
1. Personal Information
Photo
(taken within 3
months)
Please
write your
name on the
back of your
photo.

* Please fill in the form in BLOCK


Full Name (Exactly the same as your passport)
English
TARO YAMADA

Name

Given name (English)

Family Name (English)

TARO

YAMADA

Full Name (in Mother language)

Date of Birth

Day/Month/Year 25/12/1989

Japanese

Nationality
Religion

Buddhist
Hindu

Christian (Roman Catholic Protestant Other)


Muslim
Others (

Japanese

Mother Tongue

Marital Status
Type of Passport

Number
TG123456
Passport**

Date of Issue
(Day)
3

(Month)
3

Private
(Year)
2010

Diplomat

Date of Expiry
(Day)
3

Offi

(Month)
3

kita shinjyuku 1-2-4, tokyo, Japan 123-0045


Current Address
Tel 03-999-9999

Fax 03-456-9999

Mobile 030-456-9999

E-mail taro@yamada.co.jp

Full Name

TAICHI YAMADA

Contact Person
in Emergency

Address
minami shinjuku 5-6-7, tokyo, Japan 123-0099
*It shall be your parent.
*If you live with him/her,
please leave address
blank.

Tel 03-456-7890

Fax 03-456-7890
EF ver.2(April 9, 2013)

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

Mobile 03-456-7890

E-mail taichi@yamada.co.jp

Profession/Occupation:
*If you do not have phone
at your current address,
please write contact
person and number.

Name

Singer
Phone 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.

EF ver.2(April 9, 2013)

2.Health Condition
Blood Type

A B O AB

don't-know

Good

Health Condition

Medicine

Pregnancy

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
Food Allergies
pork beef chicken
(only for physical reason)
fish egg others (

mutton/lamb

shrimp

crab shellfish
)

none
Food Restriction
(for religion or
custom reason)

pork

beef

fish egg

chicken

mutton/lamb

shrimp crab shellfish

others (

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

Other Allergies and none


Restriction
dogs

cats

house dust

others (

3. Academic Details
Name of School or Organization
Shinjuku high school
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

3rd

Title (for supervisor only)


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

Level of English

TOEFL 250

Level of Japanes
EF ver.2(April 9, 2013)

Language

Speaking: Good

Fair

Poor

Speaking: Good

Fair

Poor

Writing : Good

Fair

Poor

Writing : Good

Fair

Poor

Reading : Good

Fair

Poor

Reading : Good

Fair

Poor

Other Language

Japanese
learning
experience

EF ver.2(April 9, 2013)

4. Personal Activities
Activities
Sports/Clubs

ski

Hobbies

drawing the cartoon

Academic Awards

first prize in English contest

(if any)

5. Expectations

Please describe your


expectation by
participating in this
programme.

6. Other Information
Have you ever been to Japan before?

Yes

No

If Yes, When

If Yes, what was the purpose of the visit


and where did you visit?
*In principle, any candidates who have participated in JENESYS 2.0 before are not allowed to take part again.

EF ver.2(April 9, 2013)

Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my knowle
Signature:

Date:

24

10

/ 2012

(Day/Month/Yea

Agreement of the Application Guidelines for JENESYS2.0


I hereby agree to the qualifications of health conditions and the use of my personal information for the pu
operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0.
Signature:

Date:

24

10

2012

(Day/Month/Ye

EF ver.2(April 9, 2013)

Reg.No.

fill in the form in BLOCK LETTERS.


as your passport)
TARO YAMADA
Middle Name (if any)(English)
DAVID
Nickname (Please specify
the name you would like to be called)

TARO
Age

(as of the day


of the flight to
Japan)

18
MF

Sex

SingleMarried
Passport

ate

Diplomat

Expiry
(Day)
3

Official

(Month)
3

(Year)
2010

-456-9999

taro@yamada.co.jp
Relationship
father

-456-7890
EF ver.2(April 9, 2013)

taichi@yamada.co.jp
Singer
E-mail

leave the section blank.

EF ver.2(April 9, 2013)

se etc.)

ery disease etc.)


myasthenia gravis

crab shellfish
)

crab shellfish
)

meet all the requests from the participa

Location: (city,province)
Tokyo

Tel: 03-567-1111
Fax: 03-567-1112
TOEFL 250

Level of Japanese
EF ver.2(April 9, 2013)

g: Good

Fair

Poor

: Good

Fair

Poor

: Good

Fair

Poor

Year or Month

EF ver.2(April 9, 2013)

Period of
Involvement

2 years
5 months

EF ver.2(April 9, 2013)

t to the best of my knowledge.

2012

(Day/Month/Year)

nal information for the purpose of the


YS2.0.
2012

(Day/Month/Year)

EF ver.2(April 9, 2013)