JENESYS2018 Inbound Program

Entry Form
(Culture) Japanese Language
Program Title: Communication,
Japanese Culture Exchange
Your Country: （ the Philippines）
Batch: 25th Batch (05/March -- 12/March/2019)
* Read and confirm Qualifications for Participants in the Application Guidelines for JENESYS2018
this Entry Form.
* Refer to the Sample and Fill in All the relevant Columns and Sections . Blank Columns are Not A

1. Personal Information
Full Name (Exactly the same as your Passport, mak
Photo English
Name
(taken
within 3 months)

Please write Nickname (Englis

your name on the Full Name (in Mother Language)
back of your
（the name you li
photo.

Day/Month/Year
Date of Birth Age
/　　　　 /

Nationality Sex

Marital Status Marrie Widowe Divorce

Single
d d d
Christi
Buddhist Muslim Hindu No Religion
Religion an
Other → (　　　　　　　　　　　 ）

Mother Tongue

Number Type of Passport for this v

Passport Privat Diplom

If you have no e at
passport, leave this Date of Issue Date of Expiry
section blank. Day/Month/Year Day/Month/Y
/　　　　　/ /　　　　　/

Facebook Twitter Instagram

Social Media User
Account(s)

※ Your postings may be used in the program reports or website which will be open to the

Address ：

Entry Form (JENESYS2018 Inbound) Page 1

Current Address /
 Tel ： Mobile ：
Current Address /
Phone Number
E-mail ：

※ Regarding your E-mail address, please write the most sure one, so that notices
or Japanese government will be sent to that address after the program. (only one mail
Full Name

Contact Person Relationship ： 　 Moth (

Father Other
in case of er
Emergency
*It should be your parent. Address ：

Tel ： Mobile ：

E-mail ：

*If you have no phone Contact Phone Number Holder's Name Holder's E-mail
at
your address, write a
contact phone number.

Entry Form (JENESYS2018 Inbound) Page 2

 l in All the Columns and Sections. Blank Columns
2. Health Condition
Good （Nothing to Declare
Below）
I Have Been Diagnosed (Serious
Disease)
fully
Name of Disease：( ) →
recovered
Having Chronic Disease
Health Condition → 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 obesit
renal dysfunction myas
(diabetes) y
　　　　　　　　　　→
Others ( )

Not Taking Any Medicine

Medicine
Taking Medicine Regularly → Name of Medicine： ( 　　　　　

Pregnancy → No Yes Stop the Entry Form and consult with Focal Point or Jap

No Yes
Physical Difficulty
→　If Yes, What Difficulty ? (　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
none
Food Allergies
(only for physical chicke mutton/lamb crab
pork beef shrimp
reason) n
othe
oth
fish egg →( )
rs
ers
none
Food Restriction
(for religious or pork beef chicken mutton/lamb shrimp crab sh
custom reason) oth
*Check items even if you fish egg →( )
are pure vegetarian. ers
※ Meals during the program may not meet all the requests or restrictions.

none
Other Allergies house othe →
Physical Reason： dogs cats
or Restrictions dust rs
dog house other
Religious/Custom Reason： cats →
s dust s
No Yes
Smoking Habit
※ Smoking under 20 is prohibited in Japan. This information may be used for homestay

l in All the Columns and Sections. Blank Columns

3. School /Company /Organizatio
University　/　College High School / Vocational / O
Are you Student or Graduate Student Student Student
Working Youth ? Working
Working Youth Student
Name of School Location (City or

School Field of Study or Name of Faculty / Department

Working student needs to
fill in this part.
Grade / School Year：
Job Title (for supervisor)：
Entry Form (JENESYS2018 Inbound) Page 3
 Name of Company / Organization Location (City or

Company /
Organization
Department / Division / Office
Working student needs to
fill in this part.

Job Title：
TOEI
Official English Test (If any) TOEFL(score:
) C
IEL (score: Othe
r →( )(
)　 TS
Level of English Level of Japa
Language F
Speaking ： Good Fair Poor Speaking ： Good
ai
Writing ： Good Fair Poor Writing ： Good Fa
Reading ： Good Fair Poor Reading ： Good Fa
If you have ever learned Japanese Japanese Year(s) / Month(s)
language, is your Japanese teacher a Learning
Yes No
dispatched person as "NIHONGO Experienc
Partners" by ASIA Center in Japan? e

Entry Form (JENESYS2018 Inbound) Page 4

 l in All the Columns and Sections. Blank Columns
4. Visiting Japan
Have you been to Japan before? Yes ↓ No → no need to fill in b

More than 3 months

→ Stop the Entry Form and consult with Fo

If Yes, how long did you stay in Japan? Japanese Embassy

3 months or less

JENESYS / KIZUNA SSEAYP JICA

JF JNTO HIDA

If Yes, did you join any of the following? → Stop the Entry Form and consult with Fo
Japanese Embassy

None of the above

5. Experiences related to Japan

①Are you a learner of Japanese
language, Yes No → If "Yes" How Many Years ?
or a Japan scholar?
②Have you ever been involved Yes No → If "Yes" How Many Years ?
in Japanese culture or Japanese sports?

③Have you ever been involved Yes No → If "Yes" How Many Years ?
in business related to Japan?

6. Personal Activities
Sports/Clubs → How Many Years ?

Hobbies/Favorites

Prizes/Awards
(Sports or → When ?(
Academic, if any)

7. Expectations

What Do You
Expect
in This Program ?

(Write Your Wish, Hope

or Desire for the
Program
in Relation to Your
Specific Study, Work
or Experience.)

Entry Form (JENESYS2018 Inbound) Page 5

== After you complete filling this form, please read and sign on (Annex2) Letter
Understanding JENESYS2018. ==

Entry Form (JENESYS2018 Inbound) Page 6

e

S2018 before filling out

e Not Accepted.

t, make sure to check the Endorsements)

(English)
you like to be called）

Male Female

on

r this visit
Diplom Official
at

Month/Year
　　　　　/

others

en to the public.

Entry Form (JENESYS2018 Inbound) Page 7

 notices or requests from JICE
ne mail address)

-mail

Entry Form (JENESYS2018 Inbound) Page 8

umns are Not Accepted.

under treatment
ed

ase

myasthenia gravis

　 )

or Japanese Embassy

　　　　　　　　　　　　　　)

shellfish

shellfish

( )
( )

mestay arrangement.

umns are Not Accepted.

ional / Other School

City or Province)

Entry Form (JENESYS2018 Inbound) Page 9

City or Province)

TOEI
(score: )
C
)(score: )

of Japanese
F
Poor
air
Fair Poor
Fair Poor
onth(s)

Entry Form (JENESYS2018 Inbound) Page 10

umns are Not Accepted.

fill in below.

ith Focal Point or

CA MEXT

ith Focal Point or

( year(s))

( year(s))

( year(s))

( year(s))

Entry Form (JENESYS2018 Inbound) Page 11

etter of

Entry Form (JENESYS2018 Inbound) Page 12

 JENESYS2018 Inbound Program
Entry Form

Program Title: (Culture) Japanese Culture Excha

Your Country: （ Japan ）

Batch: 1st Batch (11/September -- 18/September/2018
* Read and confirm Qualifications for Participants in the Application Guidelines for JENESYS2017
this Entry Form.
* Refer to the Sample and Fill in All the relevant Columns and Sections . Blank Columns are Not A

1. Personal Information
Full Name (Exactly the same as your Passport, mak
Photo English
Name
(taken Naomi Christine Yamad
within 3 months)

Please write Nickname (Englis

your name on the Full Name (in Mother Language)
back of your （the name you li
photo.
ナオミ　クリスティン　ヤマダ Ch

Day/Month/Year
Date of Birth Age
25/7/1992

Nationality Japanese Sex

Marital Status Marrie Widowe Divorce

Single
d d d
Christi
Buddhist Muslim Hindu No Religion
Religion an
Other → (　　　　　　　　　　　 ）

Mother Tongue Japanese

Number Type of Passport for this v

Passport JN1234567 Privat Diplom

If you have no e at
passport, leave this Date of Issue Date of Expiry
section blank. Day/Month/Year Day/Month/Y
15/3/2015 15/3/202

Facebook Twitter Instagram

Social Media User
Account(s) naomi.yamada naomin christine@naomi

※ Your postings may be used in the program reports or website which will be open to the

Address ： 2-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo, 163-0716 Japan

Enttry Form (Sample) Page 13

Current Address /
 Tel ： 03-6838-2730 Mobile ：080-1234-5678
Current Address /
Phone Number
E-mail ： chris@jice.ezweb.jp

※ Regarding your E-mail address, please write the most sure one, so that notic
JICE or Japanese government will be sent to that addtess after the program. (only one
Full Name

Ken Robert Yamada

Contact Person Moth

Relationship ： 　 ✘ Father Other (
in case of er
Emergency
*It should be your parent. Address ： 2-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo, 163-0716 Japan

Tel ： 03-6838-2730 Mobile ： 090-9012-3456

E-mail ： ken@jice.ezweb.jp

*If you have no phone Contact Phone Number Holder's Name Holder's E-mail
at
your address, write a
contact phone number.

Enttry Form (Sample) Page 14

 l in All the Columns and Sections. Blank Columns
2. Health Condition
Good （Nothing to Declare
Below）
I Have Been Diagnosed (Serious
Disease)
fully
Name of Disease：( ) →
recovered
Having Chronic Disease
Health Condition → 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 obesit
renal dysfunction myas
(diabetes) y
　　　　　　　　　　→
Others ( )

Not Taking Any Medicine

Medicine
Taking Medicine Regularly → Name of Medicine： ( 　　　　　

Pregnancy → No Yes Stop the Entry Form and consult with Focal Point or Jap

No Yes
Physical Difficulty
→　If Yes, What Difficulty ? (　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
none
Food Allergies
(only for physical chicke mutton/lamb crab
pork beef shrimp s
reason) n
othe
oth
✘ fish egg rs →( )
ers
none
Food Restriction
(for religious or pork beef chicken mutton/lamb shrimp crab sh
custom reason) oth
*Check items even if you fish egg →( )
are pure vegetarian. ers
※ Meals during the program may not meet all the requests or restrictions.
none
Other Allergies house othe →
Physical Reason： dogs cats
or Restrictions dust rs
dog house other
Religious/Custom Reason： cats →
s dust s
No Yes
Smoking Habit
※ Smoking under 20 is prohibited in Japan. This information may be used for homestay

l in All the Columns and Sections. Blank Columns

3. School /Company /Organizatio
University　/　College High School / Vocational / O
Are you Student or Graduate Student Student Student
Working Youth ? Working
Working Youth Student
Name of School Location (City or
Japan International Business School To
School Field of Study or Name of Faculty / Department
Working student needs to Accounting
fill in this part.
Grade / School Year： 2nd year
Job Title (for supervisor)：
Enttry Form (Sample) Page 15
 Name of Company / Organization Location (City or

Company / ABC International Co., Ltd. To

Organization
Department / Division / Office
Working student needs to International Investment Division
fill in this part.

Job Title： Assistant Manager

TOEI
Official English Test (If any) TOEFL(score: 100 )
C
IEL (score: Othe
→( )(
)　 TS r
Level of English Level of Japa
Language
Poor F
Speaking ： Good Fair Speaking ： Good
ai
Writing ： Good Fair Poor Writing ： Good Fa
Reading ： Good Fair Poor Reading ： Good Fa
If you have ever leared Japanese Japanese Year(s) / Month(s)
language, is your Japanese teacher a Learning
dispatched person as "NIHONGO Yes No Experienc 20
Partners" by ASIA Center in Japan? e

Enttry Form (Sample) Page 16

 l in All the Columns and Sections. Blank Columns
4. Visiting Japan
Have you been to Japan before? Yes ↓ No → no need to fill in b

More than 3 months

→ Stop the Entry Form and consult with Fo
If Yes, how long did you stay in Japan? Japanese Embassy

3 months or less

JENESYS / KIZUNA SSEAYP JICA

JF JNTO HIDA

If Yes, did you join any of the following? → Stop the Entry Form and consult with Fo
Japanese Embassy

None of the above

5. Experiences related to Japan

Are you a learner of Japanese language,
Yes No → If "Yes" How Many Years ?
or a Japan scholar?

Have you ever been involved

Yes No → If "Yes" How Many Years ?
in Japanese culture or Japanese sports?

Have you ever been involved

Yes No → If "Yes" How Many Years ?
in business related to Japan?

6. Personal Activities
Sports/Clubs Athletic Club → How Many Years ?

Hobbies/Favorites Travel, Reading (Harry Potter), Animation (One Piec

Prizes/Awards
1st Prize, Tokyo Field Competition,
(Sports or → When ?( October 200
High School Female Fast Run 100m
Academic, if any)

7. Expectations
○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○
What Do You ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○
Expect ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○
in This Program ?

(Write Your Wish, Hope

or Desire for the
Program
in Relation to Your
Specific Study, Work
or Experience.)

Enttry Form (Sample) Page 17

== After you complete filling this form, please read and sign on (Annex2) Letter
Understanding JENESYS2018. ==

Enttry Form (Sample) Page 18

Exchange

r/2018)
S2017 before filling out

e Not Accepted.

t, make sure to check the Endorsements)

Yamada

(English)
you like to be called）

Chris

26

Male Female

on

r this visit
Diplom Official
at

Month/Year
/3/2025

others

en to the public.

Japan

Enttry Form (Sample) Page 19

678

at notices or requests from

nly one mail address)

Japan

3456

-mail

Enttry Form (Sample) Page 20

umns are Not Accepted.

under treatment
ed

ase

myasthenia gravis

　 )

or Japanese Embassy

　　　　　　　　　　　　　　)

shellfish

shellfish

( )
( )

mestay arrangement.

umns are Not Accepted.

ional / Other School

City or Province)
Tokyo

Enttry Form (Sample) Page 21

City or Province)
Tokyo

r
TOEI
(score: 745 )
C
)(score: )

of Japanese
F
Poor
air
Fair Poor
Fair Poor
onth(s)

20 years

Enttry Form (Sample) Page 22

umns are Not Accepted.

fill in below.

ith Focal Point or

CA MEXT

ith Focal Point or

( year(s))

( 10 year(s))

( year(s))

( 5 year(s))

e Piece)

ber 2008 )

Enttry Form (Sample) Page 23

etter of

Enttry Form (Sample) Page 24