NATIONAL BOARD FOR THE PLACEMENT AND PROTECTION

INDONESIAN OVERSEAS WORKERS

Jl. MT. Haryono Kav. 52 Jakarta Selatan-17220, Lt. 5,
Telp./Fax. : 021-790115

Form 7

“Information Sheet of Applicants for Indonesian “Kangoshi”

Photo

Name　＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿　Sex　＿＿＿____
(Note) Fill in your name in print, as written on passport

Date of birth　＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿　Age　＿＿＿

Address　＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

Telephone number　＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

Email　
(passport holder only)

Spouse / Dependent children

Number of dependent children:
Marital Status (Married / Single)
Responsible to support your spouse (Yes / No)

(Passport holder only)

Passport number _____________________
Date of expiration (Year/Month/Day) ___________________

Education: (most recent first)

Period Nursing School / University Degree Obtained
(year / month) to (year / month) (Name / Place)
( / ) to ( / )
( / ) to ( / )
 ( / ) to ( / )

Number of certificate for qualified nurse in Japan ＿＿__________________________＿

Date of acquisition of certificate (Year/Month/Day) ________________________________

Candidate Number when you last entered Japan ID

Total period of experience as a qualified nurse in Japan ______ years and months.

Work experience (Including in Indonesia and Japan): (Most recently first. Experience as a candidate
for “kangoshi” and “Kangoshi” should be included.)

Period Characteristic of
Country Name of Hospital Occupation
(year / month) to (year / month) ward
( / ) to ( / )
( / ) to ( / )
( / ) to ( / )

Health condition　＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿_

Other descriptions(Qualifications, Japanese language proficiency, etc.)　

Request to accepting institution (If any) (ex; “I want to cook by myself because I’m allergic.” etc.)

Preference of the facility (Optional):

Name of institution / facility you wish to work
Region
Hokkaido____ Tohoku____ Kanto____ Hokuriku-Shinetsu____ Tokai____
Kinki____ Chugoku____ Shikoku____ Kyushu-Okinawa____
No Preference _____________________________
Prefecture ________________________________
Specialization __________________________　_
Holidays ________________________________　
Others _________________________________　_

Declaration of authenticity of the abovementioned items ___ (Kangoshi Signature)

Endorsement by the National Board of the abovementioned duly authenticated documents
(NBPPIOW Signature

Note 1 This form should be used for Applicants for Indonesian “Kangoshi”.
Note 2 Those who have a license for “Kangoshi” or Certificate of registration for “Kangoshi”
shall attach a copy of either one of the above mentioned certificates.
Note3 Those who have not completed the registration process shall attach a copy of the
certificate of passing the national examination for “Kangoshi” in Japan
Note4 Any other certificate related to “other description” may be attached (JLPT certificate and
etc.)
Note5 Fill this form for all applicants and gather.