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					                                                                                                 Reg.No.

                           Entry Form for JENESYS Programme
          Country:
1. Personal Information                                       * Please fill in this form in BLOCK LETTERS (English Alphabet).
                                                               Full Name (Exactly the same as your passport)
                                  Name
       Photo
   (taken within
                           Given name                           Family Name                      Middle Name (if any)
     3 months)
    Please write
   your name on
    the back of                                                Full Name (in Mother language)
    your photo.
                           Nickname/Short form of your name (What are you commonly called?)                     Gender
                                                                                                     Male                     Female

    Date of Birth          Day/Month/Year                                                             Age
                                         (City)                           (Province)                            (Country)
    Place of Birth                                                        Osaka
                             Buddhist             Christian                      Nationality
       Religion              Hindu                Muslim

                             Other
                                                                                Marital Status       Single                 Married
                                            (                    )
                           Number                                              Type of Passport
                                                                                      Private        Official               Diplomat
                           Date of Issue (Day/Month/Year)                      Date of Expiry (Day/Month/Year)
     Passport**

                           Place of Issue                                      Issuing Authority


                                     Given Name                         Family Name              Middle Name (relationship)

                           Address:

  Home address &
  person to contact in
   case of emergency
                           Tel:                                                Fax:
                           Mobile:                                             E-mail:
                           Profession/Occupation:
                           Address:

  Current Address
 * if you do not live at
 home (above address)
                           Tel:                                                Fax:
                           Mobile:                                         E-mail:
 *If you do not have       Name                                 Phone Number                     E-mail
    phone at home:
   Contact Person
                                                                                                 *continued overleaf
**Passport: Only a person who has a valid passport fills in the "passport" section. As for a person who doesn't have a
passport, please leave the section blank.
2.Medical History
    Blood Type             A                      B                        O                    AB                      Don’t' Know
                            Good
  Health Condition
                            Chronic illness or any problem            (Please describe you condition:           )

                            Dogs           Cats          Others (      (                       )
Allergies to Animals
                       Reasons:            Allergy           Religious reasons            Others (                                      )
                       Please check the boxes below which you cannot eat due to religion or allergies.
 Food Allergies or
                            Pork                  Beef                     Chicken              Mutton/Lamb             Shellfish              Egg
    Restriction
                            Others     (                                                                                                                    )

3. Professional Career
                       Name of School or Organization                                                               Location: (city,province)
Information of your
    Organization    Tel:                                                                     Title:
                       Fax:                                                                  Grades/School Year:
                       English Proficiency                                                                              Mother
                       certificated score (if any, e.g.
                       TOEFL)                                                                                           Tongue
                                           Level of English                                                 Level of Japanese
                       Speaking:                  Good              Fair        Poor         Speaking:                  Good           Fair          Poor
     Language
                       Writing:                   Good              Fair        Poor         Writing:                   Good           Fair          Poor

                       Reading:                   Good              Fair        Poor         Reading:                   Good           Fair          Poor
                            Other                                                              Japanese
                         Language:                                                              learning            Year or Month
                       Written/Spoken                                                          experience

4. Personal Activities
                                                                                                                                                Period of
                                                  Activities                                            Position Held
                                                                                                                                              Involvement
       Sports

       Clubs

Special Knowledge

Academic Awards

5. Other Information
Have you ever been to Japan before? Yes                                    No                If Yes, When?

If Yes, Where did you visit?
Do you have any particular
concerns on visiting Japan? If yes,
what are they?
Area Representation (based on                     NCR               Luzon            Visayas         Mindanao
School location)
Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my
knowledge.

Agreement of the Use of Personal Information
I agree that my personal information in the Entry Form, provided to Japan InternationCooperation Center
(JICE), will be used only for the purpose of the operation of JENESYS programme.

                 Signature:                                                          Date:              /           /               (Day/Month/Year)
                                                                                                          -SAMPLE-
                                                                                                       Reg.No.

                           Entry Form for JENESYS Programme
          Country:                         Philippines


1. Personal Information                                        * Please fill in this form in BLOCK LETTERS (English Alphabet).
                                                                Full Name (Exactly the same as your passport)
                                  Name
      Photo
  (taken within
                                                                                  Taro YAMADA
                           Given name                             Family Name                          Middle Name (if any)
    3 months)
   Please write
  your name on                           Taro                               YAMADA                                    David
   the back of                                                  Full Name (in Mother language)
   your photo.
                                                                             山田太郎
                           Nickname/Short form of your name (What are you commonly called?)                           Gender

                                                               Dev                                          Male                    Female

    Date of Birth          Day/Month/Year                      23-Dec-1992                                  Age                   18
                                          (City)                                 (Province)                           (Country)
    Place of Birth                 Ikeda-City                     Ilocos Norte   Osaka                            Japan
                              Buddhist             Christian                           Nationality              Japanese
       Religion               Hindu                Muslim

                              Other
                                                                                      Marital Status       Single                 Married
                                             (                    )
                           Number                                                     Type of Passport
                                          P0123456789                                     Private          Official               Diplomat
                           Date of Issue (Day/Month/Year)                             Date of Expiry (Day/Month/Year)
     Passport**
                                           4-Jan-2009                                                3-Jan-2014
                           Place of Issue                                             Issuing Authority
                                          Metro Manila                                                   MOFA
                                      Given Name                             Family Name               Middle Name (relationship)
                                         Henry                               Yamada                          -              Father
                           Address:

  Home address &              Nittochi Building 20F, 6-10-1 Nishi-Shinjuku, Shinjuku-
  person to contact in
   case of emergency
                                             Ward, Tokyo Prefecture, Japan
                           Tel:             03-5322-2548   Fax:          03-5322-2590
                           Mobile:         090-1234-5678 E-mail:        jicetaro@jice.org
                           Profession/Occupation:          Government Official
                           Address:
                                         Room 101, 1-1-1 Kasumigaseki, Koto-Ward,
  Current Address
 * if you do not live at                         Tokyo Prefecture, Japan
 home (above address)
                           Tel:              03-9999-9999    Fax:         03-0001-0001
                           Mobile:          080-9999-1111 E-mail:      jenesys@jenesys.co.jp
 *If you do not have       Name                                   Phone Number                         E-mail
    phone at home:
                             Annne TANAKA                               03-0001-0001                                   N/A
   Contact Person
                                                                                                       *continued overleaf
**Passport: Only a person who has a valid passport fills in the "passport" section. As for a person who doesn't have a
passport, please leave the section blank.
2.Medical History
     Blood Type            A                     B                        O                   AB                      Don’t' Know
                            Good
  Health Condition
                            Chronic illness or any problem           (Please describe you condition: cardiac disease          )

                            Dogs          Cats          Others (     (                        )
Allergies to Animals
                       Reasons:           Allergy           Religious reasons            Others (                                   )
                       Please check the boxes below which you cannot eat due to religion or allergies.
 Food Allergies or                                                                                Mutton/Lamb
                            Pork                 Beef                     Chicken                                      Shellfish            Egg
    Restriction
                            Others                        (Need           to take a lot of water every day )
3. Professional Career
                       Name of School or Organization                                                               Location: (city,province)
Information of your   Japan            International Cooperation Center                                             Quezon

    Organization    Tel:                             03-5322-2548                         Title:           Deputy                       Chief
                       Fax:                          03-5322-2590                         Grades/School Year:
                       English Proficiency                                                                             Mother
                       certificated score (if any, e.g.              TOEFL 250                                         Tongue
                                                                                                                                        Japanese
                       TOEFL)
                                         Level of English                                                   Level of Japanese
                       Speaking:                 Good              Fair        Poor       Speaking:                    Good         Fair          Poor

     Language          Writing:                                                           Writing:
                                                 Good              Fair        Poor                                    Good         Fair          Poor

                       Reading:                  Good              Fair        Poor       Reading:                     Good         Fair          Poor
                           Other                                                              Japanese
                        Language:                    Basic French                              learning             Year or Month 6         months
                       Written/Spoke                                                          experience

4. Personal Activities
                                                                                                                                             Period of
                                                 Activities                                              Position Held
                                                                                                                                           Involvement
       Sports          Badminton, Dancing & Skiing                                                        Player                           00-present

       Clubs           Tennis Club                                                                Vice President                        01-09 Spring

Special Knowledge      Computer Graphics                                                                        -                                 -

Academic Awards JICE Award for Excellence                                                                       -                       2006 2nd term

5. Other Information
Have you ever been to Japan before? Yes                                   No              If Yes, When?                       2000 Jun
If Yes, Where did you visit?                                                             Hokkaido
Do you have any particular
concerns on visiting Japan? If yes,         Language barrier
what are they?
Area Representation (based on                                      Luzon
                                                 NCR                                Visayas         Mindanao
School location)
Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my
knowledge.

Agreement of the Use of Personal Information
I agree that my personal information in the Entry Form, provided to Japan InternationCooperation Center
(JICE), will be used only for the purpose of the operation of JENESYS programme.

                  Signature:                                                    Date:                /          /             (Day/Month/Year)
国・地域名(和文)             国・地域名(英文)           州・県名(英文)

フィリピン       Philippines           Abra
フィリピン       Philippines           Agusan del Norte
フィリピン       Philippines           Agusan del Sur
フィリピン       Philippines           Aklan
フィリピン       Philippines           Albay
フィリピン       Philippines           Antique
フィリピン       Philippines           Apayao
フィリピン       Philippines           Aurora
フィリピン       Philippines           Bataan
フィリピン       Philippines           Basilan
フィリピン       Philippines           Benguet
フィリピン       Philippines           Biliran
フィリピン       Philippines           Bohol
フィリピン       Philippines           Batangas
フィリピン       Philippines           Batanes
フィリピン       Philippines           Bukidnon
フィリピン       Philippines           Bulacan
フィリピン       Philippines           Cagayan
フィリピン       Philippines           Camiguin
フィリピン       Philippines           Camarines Norte
フィリピン       Philippines           Capiz
フィリピン       Philippines           Camarines Sur
フィリピン       Philippines           Catanduanes
フィリピン       Philippines           Cavite
フィリピン       Philippines           Cebu
フィリピン       Philippines           Compostela Valley
フィリピン       Philippines           Davao Oriental
フィリピン       Philippines           Davao del Sur
フィリピン       Philippines           Davao del Norte
フィリピン       Philippines           Eastern Samar
フィリピン       Philippines           Guimaras
フィリピン       Philippines           Ifugao
フィリピン       Philippines           Iloilo
フィリピン       Philippines           Ilocos Norte
フィリピン       Philippines           Ilocos Sur
フィリピン       Philippines           Isabela
フィリピン       Philippines           Kalinga
フィリピン       Philippines           Laguna
フィリピン       Philippines           Lanao del Norte
フィリピン       Philippines           Lanao del Sur
フィリピン       Philippines           Leyte
フィリピン       Philippines           La Union
フィリピン       Philippines           Marinduque
フィリピン       Philippines           Maguindanao
フィリピン       Philippines           Masbate
フィリピン       Philippines           Mindoro Occidental
フィリピン       Philippines           Mindoro Oriental
フィリピン       Philippines           Mountain Province
フィリピン       Philippines           Misamis Occidental
フィリピン       Philippines           Misamis Oriental
フィリピン       Philippines           Cotabato (North Cotabato)
フィリピン       Philippines           Negros Occidental
フィリピン       Philippines           Negros Oriental
フィリピン       Philippines           Northern Samar
フィリピン   Philippines   Nueva Ecija
フィリピン   Philippines   Nueva Vizcaya
フィリピン   Philippines   Pampanga
フィリピン   Philippines   Pangasinan
フィリピン   Philippines   Palawan
フィリピン   Philippines   Quezon
フィリピン   Philippines   Quirino
フィリピン   Philippines   Rizal
フィリピン   Philippines   Romblon
フィリピン   Philippines   Sarangani
フィリピン   Philippines   South Cotabato
フィリピン   Philippines   Siquijor
フィリピン   Philippines   Southern Leyte
フィリピン   Philippines   Sulu
フィリピン   Philippines   Sorsogon
フィリピン   Philippines   Sultan Kudarat
フィリピン   Philippines   Surigao del Norte
フィリピン   Philippines   Surigao del Sur
フィリピン   Philippines   Tarlac
フィリピン   Philippines   Tawi-Tawi
フィリピン   Philippines   Samar (Western Samar)
フィリピン   Philippines   Zamboanga del Norte
フィリピン   Philippines   Zamboanga del Sur
フィリピン   Philippines   Zambales
フィリピン   Philippines   Zamboanga Sibugay

				
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