Reg.No.

Entry Form for JENESYS 2.0

Traditional Culture / Heritage / Art (
1. Personal Information
Photo (taken
within 3
months)
Please write
your name on
the back of
your photo.

Date of Birth

Batch)

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

Full Name (Exactly the same as your passport)

Name
Given name (English)

Family Name (English) Middle Name (if any)(English)

Nickname (Please

specify
the name you would like to be called)

Full Name (in Mother language)

Age (as of the

day of the flight to
Japan)

Day/Month/Year

Nationality
Religion

Buddhist
Hindu

Christian (Roman Catholic Protestant Other)

Muslim
Others (

Marital Status

Mother Tongue
Number
Passport**

MF

Sex

Date of Issue
(Day)

SingleMarried

Type of Passport
Private Diplomat
(Month)

(Year)

Date of Expiry
(Day)

Official

(Month)

(Year)

Address
Current Address

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

Tel

Fax

Mobile
Full Name

E-mail
Relationship

Address

Tel

Fax

Mobile

E-mail

Profession/Occupation
*If you do not have
Name
Phone Number
E-mail
phone at your current
address,Ifplease
**Passport:
you havewrite
a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
contact person and

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

2013)

2.Health Condition
Blood Type

* Please fill in the form in BLOCK LETTERS in English

A B O AB

don't-know

Good
Previously diagnosed disease:
(
Health Condition

Medicine

Pregnancy

Food Allergies
(only for physical
reason)

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 regularlly (Specified

Yes No
none
pork

beef

fish egg

chicken

mutton/lamb

shrimp

crab shellfish

others (

none
Food Restriction
(for religion or
custom reason)

pork beef chicken

fish egg others (

mutton/lamb

shrimp crab shellfish

)

*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

3. Academic Details

others (

* Please fill in the form in BLOCK LETTERS in English

Location: (city,province)

Name of School or 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)

Tel:
Fax:

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

Level of English

Language

Level of Japanese

Speaking: Good

Fair

Poor

Speaking: Good

Fair

Poor

Writing : Good

Fair

Poor

Writing : Good

Fair

Poor

Reading : Good

Fair

Poor

Reading : Good

Fair

Poor

Other Language

Japanese Year or Month

learning
experience

4. Personal Activities

* Please fill in the form in BLOCK LETTERS in English

Period of
Involvement

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?

* Please fill in the form in BLOCK LETTERS in Englis

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 2.0 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)