Entry Form for JENESYS2015

India 1st Batch: Science and Technology

1. Personal Information
Name

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

Date of Birth

* Please fill in the form in BLOCK LETTERS in E

Full Name (Exactly the same as your passport)
English

Given name (English)

Family Name (English)

Full Name (in Mother language)

Day/Month/Year

Nationality
Religion

Buddhist
Hindu

Christian (Roman Catholic Protestant Other) Not Applicable

Muslim
Others (

Mother Tongue

Marital Status
Type of Passport

Number

Private
Passport**

Date of Issue
(Day)
Facebook

(Month)

(Year)

Diplomat

Date of Expiry
(Day)

Twitter

(Month

Instagram

SNS User Name

*on a voluntary basis

MOFA and JICE might use your postings related to JENESYS through above mentioned SN
website, that will possibly be open to the public.

Address
Current Address
Tel

Fax

Mobile
Full Name

E-mail

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

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

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

Tel

Fax

Mobile

E-mail

Profession/Occupation
*If you do not have a phone at Name

Phone Number

your current address, please

write a 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 LET

A B O AB

I don't-know

Good
Previously diagnosed serious disease:
(
Health Condition

Medicine

Pregnancy

: fully recovered / under tre

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 medicine
Taking medicine regularly (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 th

Other Allergies and none

Restriction
dogs
Yes
Smoking Habit

cats

house dust

others (

No

Smoking is prohibitted by Japanese Law in case you are under the age of 20.
JICE make use of this information only for the homestay arrangement.

3. Academic Details/Organization

* Please fill in the form in BLOCK LET

Name of School or Organization

Information of your
School/Organization

Field of study or Department

Write your
Organization if you are
Grade/school year (for student)
not 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
Speaking

Good

Fair

Poor

Level of Japan
Speaking

Good

Fair

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

Language

Good

Fair

Poor

Writing

Good

Fair

Reading

Good

Fair

Poor

Reading

Good

Fair

Writing

Other Language

Japanese
learning
experience

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

4. Personal Activities

* Please fill in the form in BLOCK LET

Activities
Sports/Clubs
Hobbies

Academic Awards
(if any)

5. Expectations

* Please fill in the form in BLOCK LET

Please describe your

expectation by
participating in this
programme.

6. Other Information

* Please fill in the form in BLOCK LET

Have you ever been to Japan before?

If Yes,your visit is financed by

Yes

Yourself

Japanese government,
JICA, Japan Foundation,
JOCA

If Yes, when, what was the purpose of the

visit and where did you visit?

Japan International Cooperation Center 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 kno
Signature:

Date:

(Day/Month/Year)

Agreement of the Application Guidelines for JENESYS2015.

I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2015.
Signature:

Date:

(Day/Month/Yea

Parent/guardian (if applicant is under 18 years of age) :

Signature:

Date:

(Day/Month/Yea

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

Reg.No.

15
hnology

n BLOCK LETTERS in English.

as your passport)

Middle Name (if any)(English)

Nickname (Please specify

the name you would like to be called)

Age

(as of the day

of the flight to
Japan)

MF

Sex

) Not Applicable

SingleMarried
Passport

ate

Diplomat

Expiry
(Day)
Instagram

Official

(Month)

(Year)
others

ough above mentioned SNS in our reports and

Relationship

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


E-mail

leave the section blank.

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

ll in the form in BLOCK LETTERS in English.

y recovered / under treatment)

se etc.)

tery disease etc.)

myasthenia gravis

crab shellfish
)

crab shellfish
)

meet all the requests from the participa

20.

ll in the form in BLOCK LETTERS in English.

Location: (city,province)

Tel:
Fax:

Level of Japanese
Good

Fair

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

Good

Fair

Poor

Good

Fair

Poor

Year or Month

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

ll in the form in BLOCK LETTERS in English.

Period of
Involvement

ll in the form in BLOCK LETTERS in English.

ll in the form in BLOCK LETTERS in English.

No

Others
(
)

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

t to the best of my knowledge.

(Day/Month/Year)

NESYS2015.
(Day/Month/Year)

(Day/Month/Year)

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

Entry Form for JENESYS2015

(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

Facebook
SNS User Name
*on a voluntary basis

Private
(Year)
2010

Date of Expiry
(Day)
3

Twitter

yamada taichi

Diplomat

Offi

(Month)
3

Instagram

taichi-yamada

MOFA and JICE might use your postings related to JENESYS through above mentioned SNS in
website, that will possibly be open to the public.

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
Contact Person

TAICHI YAMADA
EF ver.2(April 9, 2013)

Full Name

TAICHI YAMADA

Contact Person
in Emergency

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

Tel 03-456-7890

Fax 03-456-7890

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
Previously diagnosed serious disease:
(

Health Condition

Medicine

Pregnancy

: fully recovered / under treatm

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 regularly (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
Yes
Smoking Habit

cats

house dust

others (

No

Smoking is prohibitted by Japanese Law in case you are under the age of 20.
JICE make use of this information only for the homestay arrangement.

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
EF ver.2(April 9, 2013)

Information of your
School/Organization

Title (for supervisor only)

English Proficiency

TOEFL 250

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

Level of English
Language

Level of Japanes

Speaking

Good

Fair

Poor

Speaking

Good

Fair

Po

Good

Fair

Poor

Writing

Good

Fair

Po

Writing

Reading

Good

Other Language

Fair

Poor

Reading Good

Fair

Japanese
learning
experience

EF ver.2(April 9, 2013)

Po

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
*Applicants who have participated in the programme organized by the Japanese Government before are not allowed

Have you ever been to Japan before?

If Yes,your visit is financed by

Yes

Yourself

Japanese government,
JICA, Japan Foundation,
JOCA

If Yes, when, what was the purpose of the

visit and where did you visit?
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 JENESYS2015

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 JENESYS2015.
Signature:

Date:

24

10

2012

(Day/Month/Ye

Parent/guardian (if applicant is under 18 years of age) :

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
Instagram

Official

(Month)
3

(Year)
2010
others

ough above mentioned SNS in our reports and

03-456-9999

taro@yamada.co.jp
Relationship
father
EF ver.2(April 9, 2013)

Relationship
father

03-456-7890

taichi@yamada.co.jp
Singer
E-mail

leave the section blank.

EF ver.2(April 9, 2013)

y recovered / under treatment)

se etc.)

ery disease etc.)

myasthenia gravis

crab shellfish
)

crab shellfish
)

meet all the requests from the participa

20.

Location (city,province)
Tokyo

Tel: 03-567-1111
EF ver.2(April 9, 2013)

Fax: 03-567-1112
TOEFL 250

Level of Japanese

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

ent before are not allowed to take part again.

No

Others
(
)

EF ver.2(April 9, 2013)

t to the best of my knowledge.

2012

(Day/Month/Year)

nal information for the purpose of the

YS2015.
2012

2012

(Day/Month/Year)

(Day/Month/Year)

EF ver.2(April 9, 2013)