Entry Form for JENESYS 2.

0
Traditional Culture / Heritage / Art ( 9th Batch) 1. Personal Information
Name * Please fill in the form in BLOCK LETTERS in English. Full Name (Exactly the same as your passport) English Family Name (English) Middle Name (if any)(English)

Given name (English)

Full Name (in Mother language)

Nickname (Please specify the name you would like to be called)

Date of Birth

Day/Month/Year

Age (as of the day of the flight to Japan) Sex

Nationality Religion Mother Tongue Number Passport**

Buddhist Hindu Christian (Roman Catholic Protestant Other) Muslim Others (

Marital Status

SingleMarried

Type of Passport Private Diplomat (Month) Official (Year)

Date of Issue (Day) Address

(Month)

(Year)

Date of Expiry (Day)

Current Address

Tel Mobile Full Name

Fax E-mail

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

Contact Person in Emergency *It shall be your parent. *If you live with Tel him/her, please leave address blank. Mobile
*If you do not have phone at your current address, please write contact person and number.

Fax E-mail Phone Number E-mail

Profession/Occupation Name

**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.

2.Health Condition
Blood Type A B O AB Good Previously diagnosed disease: ( Health Condition

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

don't-know

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

Medicine

Taking medicines regularlly (Specified

Pregnancy

Yes No

Food Allergies (only for physical reason)

none pork beef chicken mutton/lamb shrimp crab shellfish ) null

fish egg none

others (

Food Restriction (for religion or custom reason)

pork

beef

chicken

mutton/lamb

shrimp crab shellfish )

fish egg

others (

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

Other Allergies and none Restriction dogs

cats

house dust

others (

3. Academic Details
Name of School or Organization

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

Location: (city,province)

Information of your School/Organization

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 Title (for supervisor only)
English Proficiency certificated score (if any, e.g. TOEFL)

Tel: Fax:

Level of English
Speaking: Good Language Writing : Good Reading : Good Other Language Fair Fair Fair Poor Poor Poor

Level of Japanese
Speaking: Good Writing : Good Reading : Good Fair Fair Fair Poor Poor Poor

Japanese Year or Month learning experience

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

4. Personal Activities
Activities Sports/Clubs Hobbies

Academic Awards (if any)

5. Expectations

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

Please describe your expectation by participating in this programme.

6. Other Information
Have you ever been to Japan before? If Yes, what was the purpose of the visit and where did you visit?
Yes No

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

If Yes, When?

*Applicants who have participated in the programme organized by Japanese Government before are not allowed to take part again.

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

Signature:

Date:

(Day/Month/Year)

Agreement of the Application Guidelines for JENESYS2.0 I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2.0. Signature: Date: / / (Day/Month/Year)

Reg.No.

LOCK LETTERS in English. ur passport)

ddle Name (if any)(English)

ckname (Please specify e name you would like to called)

MF

SingleMarried

Diplomat (Month)

Official (Year)

Relationship

mail

eave the section blank.

orm in BLOCK LETTERS in English.

ease etc.)

artery disease etc.) ity myasthenia gravis

crab shellfish )

null

p crab shellfish )

ll the requests from the participants.

orm in BLOCK LETTERS in English.

cation: (city,province)

l:

x:

el of Japanese
Fair Fair Fair Poor Poor Poor

od

od

od

ar or Month

orm in BLOCK LETTERS in English.

Period of Involvement

orm in BLOCK LETTERS in English.

orm in BLOCK LETTERS in Englis .

to take part again.

rrect to the best of my

Day/Month/Year)

for JENESYS2.0.

Day/Month/Year)

Entry Form for JENESYS 2.0

(Japan
1. Personal Information
Name * Please fill in the form in BLOCK LETTERS. Full Name (Exactly the same as your passport) English TARO YAMADA Family Name (English) Middle Name (if any)(English) YAMADA DAVID Nickname (Please specify the name you would like to be called) TARO Age (as of the day of the flight to Japan) Sex

Given name (English) TARO

Full Name (in Mother language)

Day/Month/Year 25/12/1989

Date of Birth

Nationality Religion Mother Tongue Number

Buddhist Hindu

Japanese
Christian (Roman Catholic Protestant Other) Muslim Others (

Japanese
TG123456

Marital Status

SingleMarried

Type of Passport Private (Year) 2010 Diplomat (Month) 3 Official (Year) 2010

Passport**

Date of Issue (Day) 3

(Month) 3

Date of Expiry (Day) 3

kita shinjyuku 1-2-4, tokyo, Japan 123-0045 Current Address Tel 03-999-9999 Mobile 030-456-9999 Full Name TAICHI YAMADA Fax 03-456-9999 E-mail taro@yamada.co.jp

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

Contact Person in Emergency *It shall be your parent. *If you live with Tel 03-456-7890 him/her, please leave address blank. Mobile 03-456-7890 Profession/Occupation:
*If you do not have phone at your current address, please write contact person and number.

Fax 03-456-7890 E-mail taichi@yamada.co.jp Singer Phone Number E-mail

Name

**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.

2.Health Condition
Blood Type A B O AB Good don't-know

Health Condition

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 Medicine Taking medicines regularlly (Specified )

Pregnancy

Yes No

Food Allergies (only for physical reason)

none pork beef chicken mutton/lamb shrimp crab shellfish ) null

fish egg none

others (

Food Restriction (for religion or custom reason)

pork

beef

chicken

mutton/lamb

shrimp crab shellfish )

fish egg

others (

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

Other Allergies and none Restriction dogs

cats

house dust

others (

3. Academic Details
Name of School or Organization Location: (city,province)

Information of your School/Organization

Shinjuku high school

Information of your School/Organization

Tokyo

Field of study(for university student only) 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)

3rd

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

Level of English
Speaking: Good Language Writing : Good Reading : Good Other Language Fair Fair Fair Poor Poor Poor

Level of Japanese
Speaking: Good Writing : Good Reading : Good Fair Fair Fair Poor Poor Poor

Japanese Year or Month learning experience

4. Personal Activities
Activities Sports/Clubs Hobbies ski drawing the cartoon

Academic Awards (if any)

first prize in English contest

5. Expectations

Please describe your expectation by participating in this programme.

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

Yes

No

If Yes, When?

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

Signature:

Date:

24

10

/ 2012

(Day/Month/Year)

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 purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0.

Reg.No.

he form in BLOCK LETTERS. ur passport)

YAMADA

ddle Name (if any)(English)

DAVID

ckname (Please specify e name you would like to called) TARO

18
MF

SingleMarried

Diplomat (Month) 3

Official (Year) 2010

99

yamada.co.jp Relationship father

90

@yamada.co.jp

nger

mail

eave the section blank.

ease etc.)

artery disease etc.) ity myasthenia gravis

crab shellfish )

null

p crab shellfish )

ll the requests from the participants.

cation: (city,province)

Tokyo

l: 03-567-1111

x: 03-567-1112

FL 250

el of Japanese
Fair Fair Fair Poor Poor Poor

od

od

od

ar or Month

Period of Involvement

2 years 5 months

rrect to the best of my

(Day/Month/Year)

ersonal information for tion Guidelines for