Curriculum Vitae for the Applicant for

International Youth Development Exchange Program (INDEX)

Please enter this excel form or type clearly in E

Country

Leader / Participant □ Leader □ Participant

(as shown in passport)

(First) (Middle) (Family)

Name

Your name will be described as shown in passport in the program official documents. If you prefe

other description, specify: (

Sex □ Male □ Female

Date of Birth （YYYY/MM/DD) YYYY/MM/DD Age

Nationality

Number
□ General □ Official □ Diplomatic
Passport for Public Official if
Information using your official
Type passport to enter
Japan

Date of issue YYYY/MM/DD Date of expiry YYYY/MM/DD

Address

E-mail
Contact
Information
Home phone Mobile phone

FAX

□ Employee (Government) □ Employee (Private)

□ Employee (NGO/NPO) □ Self-employed
Occupation
□ Teacher □ Student
□ Other (

Name

Office or School Title E-mail

Phone FAX

Name Relationship

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Emergency
 Address
Emergency E-mail
Contact
Home phone Mobile phone

FAX

Native language
Language Other linguistic
ability (other
than English)

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 □ Buddhism □ Hinduism □ Other
Religion
□ Christian □ Islam （

Involvement in youth activities

(Name of organizations, record of
youth activities, etc.)

Experiences of international
exchange programs
(Exchange countries, details)

Special skills

Matters of interest about Japan

□ Yes □ No
Experience of travel to Japan
（Date and purpose:
Are any of the following applicable to you?

□ Yes □ No

Applicants from Republic of
Austria,Republic of Chile,
Dominican Republic, Republic
of Latvia only.
Criminal record, etc.
※ “Criminal record, etc.” shall be connected to prostitution.
filled by applicants from the
countries of the visa exemption
arrangement being set to enter
Japan.
You have:
◆been convicted of a crime or offence in any country.
◆been sentenced to imprisonment for 1 year or more in any country.
◆been deported or removed from Japan or any country for overstaying your visa or
violating any law or regulation.
◆been convicted and sentenced for a drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances.
◆engaged in prostitution, or in the intermediation or solicitation of a prostitute for othe
persons, or in the provision of a place for prostitution, or any other activity directly
◆committed trafficking in persons or incited or aided another to commit such an offen
*Under the Immigration Control and Refugee Recognition Act, a person who are applica
to any of these category mentioned above cannot enter Japan in principle.
If you are applicable to any of the category mentioned above, please consult a person in
charge of the matter of your government as a special request may be necessary for an
entrance.
(These items are the same as the ones appear in an ordinary visa application.)

The information that you provide may be used for the selection and determination of the invitees.
As for the actual invitees, necessary information may be used for 1) the execution of the program and 2) the establishmen
and maintenance of the network of ex-participants. Also, these information may be provided for the other invitees and tho
who are concerned with the program for the purpose of 1) and provide for the post-program activities organization
(International Youth Exchange Organization of Japan (IYEO)) for the purpose of 2) respectively
All data is securely held in accordance with ‘Act for Protection of Personal Data Held by Administrative Organs.’

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 (Attachment 3)

(INDEX)
xcel form or type clearly in English

Photograph

- 4.5 cm X 3.5 cm
- Upper half of body
- No hat
- Plain background
- Within the past six
months

m official documents. If you prefer

/DD

4/15
5/15
 ）

ny country.
r overstaying your visa or

country in violation of law

hotropic substances.
tation of a prostitute for other
ny other activity directly

her to commit such an offence.

Act, a person who are applicable

apan in principle.
ve, please consult a person in
est may be necessary for an

ary visa application.)

tees.
gram and 2) the establishment
for the other invitees and those
activities organization
ly
ministrative Organs.’

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 Personal Health Report
International Youth Development Exchange Program (INDEX)
◆This form is to be used for program preparation. Please fill in all the questions below.

Country

Name

Q１. Do you have any disease or had in the past?

□ Yes □ No
*If YES, please discribe more details.
Disease Present condition

Q２. Do you take any medicines regularly?

□ Yes □ No
*If YES, please discribe more details.
Kind/name of medicine When do you take? How often do you take?

Q３. Do you have any food restrictions or allergy?

□ Yes Reason: □ Allergy → Please describe more details in Q6.
□ Religion
□ Vegetarian
□ Others （
□ No

◇If YES, please check in the boxes of the items that you CANNOT eat or drink.
□ Non-haral food □ Eggs
□ Non-kosher food □ Milk
□ Meat □ Other dairy (cheese, yogurt etc.)
Specify: □ Peanuts
□ Pork □ Nuts
□ Chicken □ Gluten (wheat)
□ Beef □ Buckwheat (soba)
□ Other animal meat □ Alcohol

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 □ Meat extract □ Caffeine
□ Fish/Seafood □ Others （
Specify:
□ Fish (cooked)
□ Raw fish
□ Shellfish (clams, oysters etc.)
□ Crabs
□ Shrimps
□ Fish/Seafood extract
□ Roe (fish eggs)

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 Q４. Do you have any allergy other than food?
□ Yes → Please describe more details in Q6.
Specify:
□ Cats □ Dust □ Pollen (hey fever)
□ Dogs □ Penicillin □ Others （
□ No

Q５. Do you smoke?

□ Yes (Smoker)
□ No (Non-smoker)

Q６. Please describe more details of your allergy, if your answer is YES for Q3 and/or Q4.

Allergen Symptom Care to the symptom

Please describe any concerns for your health conditions during your stay in Japan if any.

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 (Attachment 4)

rogram (INDEX)
elow.

o you take?

etails in Q6.

eat or drink.

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）

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 ）

or Q3 and/or Q4.

n Japan if any.

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 (Attachment 3)

Curriculum Vitae for the Applicant for

2018 International Youth Development Exchange Program
Please enter this excel form or type clearly in English

Country

Leader / Participant □ Leader □ Participant Photograph

- 4.5 cm X 3.5 cm
(as shown in passport)
- Upper half of body
- No hat
- Plain background
- Within the past six
(First) (Middle) (Family) months
Name

Your name will be described as shown in passport in the program official documents. If you prefer

other description, specify: ( )

Sex □ Male □ Female

Date of Birth （YYYY/MM/DD) YYYY/MM/DD Age

Nationality

Number
Passport Type □ Official □ General □ Diplomatic
Information (for Public Official if using
your official passport to
enter Japan)

Date of issue YYYY/MM/DD Date of expiry YYYY/MM/DD

Address

E-mail
Contact
Information
Home phone Mobile phone

FAX

□ Employee (Government) □ Employee (Private)

□ Employee (NGO/NPO) □ Self-employed
Occupation
□ Teacher □ Student
□ Other ( )

Name

Office or School Position E-mail

Phone FAX

Name Relationship

Address
Emergency
E-mail
Contact
Home phone Mobile phone

FAX

Mother tongue
Language

13/15
Language Other linguistic
ability (other
than English)

□ Buddhism □ Hinduism □ Other

Religion
□ Christian □ Islam （ ）

14/15
Involvement in youth activities
(Name of organizations, record of
youth activities, etc.)

Experiences of international
exchange programs
(Exchange countries, details)

Special skills

Matters of interest about Japan

□ Yes □ No
Experience of travel to Japan
（Date and purpose: ）
□ Yes □ No

Applicants from Republic of
Chile, Dominican Republic,
Republic of Estonia and
Ireland only.
Criminal record, etc.
※ “Criminal record, etc.” shall be connected to prostitution.
filled by applicants from the
countries of the visa exemption
arrangement being set to enter
Japan.
You have:
◆been convicted of a crime or offence in any country.
◆been sentenced to imprisonment for 1 year or more in any country.
◆been deported or removed from Japan or any country for overstaying your visa or
violating any law or regulation.
◆been convicted and sentenced for a drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances.
◆engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
persons, or in the provision of a place for prostitution, or any other activity directly
◆committed trafficking in persons or incited or aided another to commit such an offence.
*Under the Immigration Control and Refugee Recognition Act, a person who may be
applicable to one of these items above cannot enter Japan in principle.
If applicable to any of these items above, please consult a person in charge of the matter of
your government as a special request may be necessary for an entrance.
(These items are the same as the ones appear in an ordinary visa application.)

The information that you provide may be used for the selection and determination of the invitees.
As for the actual invitees, necessary information may be used for 1) the execution of the program and 2) the establishment
and maintenance of the network of ex-participants. Further, these information may be provided for the other invitees and
those who are concerned with the program for the purpose of 1) and provide for the post-program activities organization
(International Youth Exchange Organization of Japan (IYEO)) for the purpose of 2) respectively
All data is securely held in accordance with ‘Act for Protection of Personal Data Held by Administrative Organs.’

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