Reg.No.Entry Form for JENESYS Programme-$3$1 1. Personal Information * Please fill in the form in BLOCK LETTERS.Full Name (Exactly the same as your passport)EnglishGiven name (English) Family Name (English)Full Name (in Mother language)Date of BirthAge (as of the starting day of the programme)

ReligionNationalityMother Tongue SingleMarriedNumber Type of Passport Private Diplomat OfficialDate of Issue Date of ExpiryRelationship=fhvProfession/Occupation*If you do not have phone at your current address, please write contact person and number.NamePhone Number E-mail **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.Contact Person in Emergency *It shall be your parent.*If you live with him/her, please leave address blank.Full Namef=1h1 v=m=d=Addressm1u=m1 h1u}vvkv . fkv. -=,=u 9999 Tel9499 Fax9499Mobile9499 E-mailf=1h1v=m=d=..},1uzvCurrent Address k1f= h1u}vvkv 4. fkv. -=,=u 994Tel99999999 Fax949999Mobile9949999 E-mailf=vv=m=d=..},-=,=uBuddhist Christian (Roman Catholic Protestant Other) Hindu MuslimOthers ( -=,=u-=,=u Marital StatusPassport** (Day)(Month)( Year) (Day)(Month)( Year)Nickname (Please specify the name you would like to be called) f=v Day/Month/Year//99Place of Birth(Province) (Country)Sex MF7kv $03/( Namef=v v=m=d=Middle Name (if any)(English)f=v v=m=d= d=v1dPhoto(taken within 3 months) Please write your name on the back of your photo.5v1d u /9/99 5v1d u /9/992.Medical HistoryBlood TypeGoodNot taking any medicinesTaking medicines regularlly (Specified)Pregnancy YesNo noneothers() nonefhvnonedogs cats house dust others ( )3. Professional CareerLocation (city,province)Speaking: Good FairPoor Speaking: Good FairPoorWriting : Good FairPoor Writing : Good FairPoorReading: GoodFairPoor Reading: Good FairPoorLanguageEnglish Proficiencycertificated score (if any, e.g. TOEFL)72()/ 9Level of English Level of JapaneseOther LanguaggeJapanese learning experienceYear or Month3vv 9Details of work Fax*1v1uz !fvv. v=vh9Food Restriction (for religion or custom reason)pork beef chicken mutton/lambshellfish egg*Please be noted that the meals provided in the programme cannot meet all the requests from the participants. Other Allergies Information of your OrganizationName of Organization8u1vv1fv 7kv7kvPosition (Title) TelHealth Condition+=v1uz hvu1 d1=- hvu1 !vuz d1= =fhm=. hvu1 fvvf1v !vuz d1= f.)1mmvud11uv f=f 7 !! 1mmvud11uv f.) hvu1 h=vf d1= uzu1f=! h=vf d1=. vu=vv =vfvv d1= f.)mf=!1 d1= d1=f)vu=! dvvuf1u1fvmv=fhu1= zv=v11uf1v d1= ,11d) fhv)./ffv uuf $ff=hd vm) =ud = ,vm11u !ffv v dfv =v v(v1vd 1u fh ,vd,=vfvv v1uf=f1u.. 0d1=! fv=fmuf f v!=fd f fh vu1 d= 1 uf vvd v fh MedicinePregnant women cannot participate in JENESYS Programme owing to the below reasons.Maternal and child healthRapid aggravation of influenza A (H1N1) Food Allergies(only for physical reason)pork beef chicken mutton/lambshellfish eggA B O ABdon't-know5v1d u /9/99 5v1d u /9/994. Personal ActivitiesPeriod of InvolvementHobbies v=vSpeciality v=v5. Other InformationYesNo If Yes, When?If you have something you want to do with or for host family, please write them.DeclarationI hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.Agreement of the Use of Personal Information I agree that my personal information in the Entry Form, provided to Japan International Cooperation Center (JICE), will be used only for the purpose of the operation of JENESYS programme. Signature: Date: 9 /9/99(Day/Month/Year)Have you ever been to Japan before? 999 -vuIf Yes, what was the purpose of the visit and where did you visit?)v -,$ 7v=1u1uz 1u 7kv*In principle, any candidates who have participated in JENESYS Programme before are not allowed to take part again.Do you have any particular concerns on visiting Japan? If yes, what are they?Activities Position Heldk1dv=1uz = =vfu5v1d u /9/99 5v1d u /9/99