Application Form for JENESYS2017 Programme

(Country: Indonesia )

1. Personal Information * Please complete the form electronic

Full Name (Exactly the same as your passport) (in English)
Name
Place your
passport photo
here. Given name (English) Family Name (English) Middle Name (English) (if an
Digital photo is
acceptable
(taken within 3
months) Full Name (in Mother language)

Date of Birth (Day) (Month) (Year)

Age (as of the
(as shown on your starting day of
passport) the programme)

Nationality Sex

Desired theme
Roma
Buddhis Christia n Othe
( Protestant ) 　
Religion t
Hind
n Cathol
Other (　　　　　　　
r
　　　　 )
Muslim ic
u s

Mother Tongue Marital Status Single

Number Type of Passport

　　 Private Diplomat
Passport**
Date of Issue Date of Expiry
(Day) (Month) (Year) (Day) (Month)

Address

Current Address

Tel: Fax:
Mobile: E-mail:
Full Name

Contact Person Address

in Emergency
*It shall be your parent.
*If you live with him/her,
please leave address
blank *It can be the head
of dormitory.
PSA Unipdu Revised on 16/10/2016
 *It shall be your parent.
*If you live with him/her,
please leave address
blank *It can be the head
of dormitory. Tel: Fax:
Mobile: E-mail:
Profession/Occupation:
Full Name
*If you do not have
phone at your current
address, please write
contact person and Phone Number: E-mail:
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.

PSA Unipdu Revised on 16/10/2016

2. Health Condition
Blood Type A B AB UNKNOWN

Good

Having Chronic disease

　Please specify:
□chronic lung disease (asthma, chronic obstructive lung disease etc.)
□immunodeficiency state (T cell immunodeficiency etc.)　
Health Condition □chronic heart disease (congenital heart disease, coronary artery disease etc.)
□metabolic disease (diabetes) renal dysfunction obesity myasthenia gravis
□infectious diseases (Specified: )
others ( )

Medical treatment cost related to the chronic disease is not covered by the programme insurance.

□Not taking any medicines

Medicine
□Taking medicines regularlly (Specified： 　　　　　　　　 　　　　　 )　
Pregnancy *Pregnant women cannot participate in JENESYS 2017 Programme
□Yes 　No owing to maternal and child health reason.
*for women

□None
Food Allergies
(which may cause Shrimp Crab Shellfish Fish Egg
allergic reaction)
□Others ( )
□None
Food Restriction Pork Beef Chicken Mutton/Lamb　 Shrimp　 Crab Shellfish
(for religion or
custom reason) Fish Egg Others ( )
*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

Dietary □None
Requirements Vegitarian Vegan Halal Others ( )

Other Allergies and □None

Restriction Dogs Cats House dust Others ( 　　　　　　　　 　　　　 )

3. Academic Details
Name of School / University Location (city,province)

Tel: Fax:

Information of your Field of study (for

School/University university student only)

Grade/school year (for student)

as of the day of the flight to
Japan

* I confirm that I am a student (possess student ID)

Yes No

PSA Unipdu Revised on 16/10/2016

 Profession/Occupation:
For Supervisor only
Title

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

Level of English Level of Japanese

Speaking : Good Fair Poor Speaking : Good Fair Poor
Language Writing : Good Fair Poor Writing : Good Fair Poor
Reading : Good Fair Poor Reading : Good Fair Poor
Japanese Year or Month
Other learning
Language experience

PSA Unipdu Revised on 16/10/2016

4. Personal Activities
Activities Period of Involvement

Sports/Clubs

Hobbies

Academic Awards
(if any)

5. Essay

1. Why do you want

to participate in the
JENESYS 2017
Programme?

2. How will your

*Please answer both questions in 250-300 words each. Please provide your respon
participation in
to these questions on a separate attachment with your full name clearly marked.
JENESYS 2017
contribute to your
current or future
career goals? Please
support your essay
with example

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 Programme before are not allowed to take part agai

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

Agreement of the Application Guidelines for JENESYS2017

I have read and understood the terms and conditions in the "Application guidelines for JENESYS2017."

PSA Unipdu Revised on 16/10/2016

 Agreement of the Handling of Personal Information
I agree that my personal information in the Application Form
will be used in accordance with the Handing of Personal Information (ANNEX).

(Day) (Month) (Year)

Signature: Date: / /

*No electronic signature will be accepted. Please print out your compelete application form and physically sign the form.

PSA Unipdu Revised on 16/10/2016

PSA Unipdu Revised on 16/10/2016
 Reg.No.

Programme

complete the form electronically

(in English)

ddle Name (English) (if any)

Femal
Male
e

Single Married

Diplomat Official

(Year)

Relationship

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 Relationship

ssport, please leave the

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e etc.)

ery disease etc.)

myasthenia gravis

the programme insurance.

　 )　　　
7 Programme

Shellfish
)
uests from the participants.

　　　　 )

cation (city,province)

Yes No

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od Fair Poor
od Fair Poor
od Fair Poor
r or Month

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riod of Involvement

se provide your response

ame clearly marked.

t allowed to take part again.

est of my knowledge.

YS2017
or JENESYS2017."

PSA Unipdu Revised on 16/10/2016

tion

NEX).

h) (Year)

nd physically sign the form.

PSA Unipdu Revised on 16/10/2016