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Region V
D I V I S I O N O f C A M A R I N E S S U R
Freedom Sports Complex, Sail Jose, Pili, Caimu ines Sur
DIVISION MEMORANDUM No. nAb . s. 2017
TO Assistant School Division Superintendent CD) Chief and SGOD Chief Public Schools District Supervisors Heads of Pu >lic Secondary Schools Schools Youi h Formation Coordinators All Others/( oncerned
FROM
SUBJECT:
srs/Cc f t ro w)ivis»n
ARNULFO M. BALANE, CESO V/ School Division Superintendent (
%
CALL FOR APPLICANTS TO THE JAPAN-EAST ASEA NETWORK OF EXCHANGE FOR STUDENTS AND YOUTH (JENESYS) 2017 PROGRAM
Date July 28, 2017
1. The Japanese Government, through the Japan International Cooperation Center (JICE) and the Japanese Embassy in Manila in partnership with the Department o f Education is now opening the application for the Japan East-Asia Network o f Exchange for Students and Youths (JENESYS) 2017.
2. For this year, there are two (2) programs under the JENESYS 2017 program through DepEd namely;
• Japan-ASEAN Rugby Youth Exchange• Japanese Language Communication/ Exchange in Japanese culture
3. The program aim to promote mutual trust and understanding among the peoples o f Japan and the Asia-Pacific region and to build a basis for future friendship and cooperation. It also encourages an understanding and dissemination o f Japan economics, society, history, diverse culture, politics and diplomatic relations.
4. Please refer to the enclosures for the details o f the program.Enclosure 1- Qualifications and Requirements for Students and Teacher
Participants Enclosure 2- Application Procedures Enclosure 3- Timeline o f Activities Enclosure 4- JENESYS 2017 Application Form Enclosure 5- VISA Application Form
5. For inquires and other details, please contact Mr. Joseph C. Cruzana our Project Development Officer at 0930-542-2225 or send email at [email protected].
6. Immediate dissemination and appropriate action o f this memorandum is desired.
One Vision and Mission
&ejjubltk<i nfl P ilip inasIlagatoaran its <£buka$pon
Tanggapan ng Pangalawang Kalihim
Each program shall have different set of qualifications and requirements:
Table 1: Important Requirements and Deadlines
Program Age Requirement Required Participants
by JICE
ApplicationDeadline*
Japan-ASEAN Rugby Youth Exchange
15-18 years old
(strictly bom between April 1, 1999 to March 31, 2002}
6 male students
6 female students
3 supervisors
August 11, 2017
Japanese Language Communication/Exchange iff .l pan<»|u» Cmltwe
15-18 years old 20Mghschool SPFL in Mhftngo : students
2 supervisors
September 8, 2017
*The applicants must submit their JENESYS 2017 appHcaXiun to their respective xtudsion office.
A. Qualifications for the Student ParticipantsS Must meet the age requirement stated abowe.s For those who wish to apply for the Japanese Language
; Cotnmimicatiem/Exchange m Japanese Owhrttre program, they vcm&t -be•. presently majoring in Special Program for Foreign Language (SPFL) inNihongo in a DepEd school.
S Philippine passport holder (valid until April 10, 2018 or later), S Mentally and physically fit to travel
S Must be presently enrolled in high schools Must have strong interest in the theme of program, Rugby Sport/Japanese
; . Language and Japanese Culture» 1 •
S. B»« riwaw l » for the Stwteat ParfciciwaatBS Accomplished JENESYS 2017 Registration Form. Fill out the form with
necessary information and answer tn BLOCK LETTERS.S Passport-sized photo. Staple the passport-sized photo taken within the
last three (3) months on the allocated space on the JENESYS 2017 Entry Form.
Office of the Undersecretary for Administration(Administrative Services, Information and Communications Technology, Disaster Risk Reduction and Management,
Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City
■Room 649, Mabmi Bttfldmg; Mobile: +639260820^2; LwidHne: +6326337203, *6326376207 Email: [email protected]; Faccbook/Twitter (gdepedtayo
JiqiuMifca ug;jJiln jijiaSl&agatoaran ng (Ebuhaspoit
Tanggapan ng Pangalawang Kalihim
S VISA Application Form. Write complete name in BLOCK LETTERS and then sign using ballpoint pen, other areas on the form must be left blank.
✓ 45mm x 45 mm photo. Staple the 45mm x 45mm photo taken within the last three (3) maathson the .allocated space on the VISA .application form.
S Original Passport (valid until April 10, 2018 or later)V Original and updated (2G17) NSO Birth Certificate. Phetoeopy and/or
Expired NSO Birth Certificate will not be accepted.S Scanned copy of Information 'Page and 'Emergency Contact Page of
PassportS Scanned copy of Official School Registration FormS DSWD Clearance. Fill out the attached DSWD Clearance Form and
submit to the nearest DSWD Field Office; DSWD Field Office may require other documentary requdjrejoiejits (For minor participants only), (fox the requirements, please refer to http://www.dswd.gov.ph/faqs/travel- cleciranc&for^minors/)
Note: Submission of plagiarized documents would mean • automatic disqualification to the program.
C. Qualification for Teacher ParticipantsS A bona fide Filipino citizen, under the age of 4£)S Philippine passport holder (valid until April 10, 2018 or later)•/ Mentally and physically fit to travelS Must have strong interest in the theme of program, Rugby Sport/Japanese
Language and Japanese Culture
B. 'Requirements for Teacher ParticipantsS - Accomplished JENESYS 2017 Registration Form. Fill out the form with
.necessary information and answer in BLOCK LETTERS.S Passport-sized photo. Staple the passport-sized photo taken within the
last three (3) months on the allocated space on the JENESYS 2017 Entry Fsaooa,
S. VISA Application Form. Write complete name in BLOCK LETTERS and .• • then «ign using ba^ok^ pen; other areas-on the form must fee left blank.• / 45mm x 45 mm photo. Staple the 45mm x 45mm photo taken within the
last three (3) months on the allocated space on the VISA application form.■/ Original Passport (valid until April 10, 2018 or later)/ Original and updated (2017) NSO Birth Certificate. Photocopy and/or
Expired NSO Birth Certificate will not be accepted.•/ Scanned copy of Information Page and Emergency Contact Page of
Passport
Office of the Undersecretary for Administration(Adnrinisuathte Siinjictifi, Irifamiatioii.amlCommumcations Technology, HjsasXerMiskJieductian auxJManagement,
Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City
ftoom 5W, Mabihi Building; Mobile: +639260320T62rLandline: ^6326337^03, +6326376207 Email: [email protected]; Faocbook/Twitter @depcdtayo
&qmbliUa ng phpinas
Eajatoaran ng CbukasfponTanggapan ng Pangalawang Kalihim
^ Original NSO-certifled Marriage Certificate. Photocopy of Marriage Certificate will not be accepted (For married participants only.)
• Approved Travel Authority (for the requirements, please refer to DepEd Order No. 43 s. 20J 4) (for xyjsMed applicants oxily)
Note: Submission of plagiarized documents would mean automatic disqualification to the program
The following are automatically disqualified:• Applicants who have already studied/stayed in Japan for over three
months period• Applicants wixo have already participated in J®NES¥S/JGZUNA, SSEAYP,
JICA, Japanese Government (Monbukagakusho: MEXT) Scholarship Program, invitation Program of Japan Foundation (JF), Japan National Tourism Organization (JNTO), or HIDA.
D. Terms and Conditions of the Program
The Japan International Cooperation Center (JICE) shall cover the ff. program- related expenses:
• Round trip economy class ticket from/to the international airport in home country to/from Japan;
• Visa application fee• Overseas travel insurance• Accommodation, transportation, and meals within the program in Japan• Admission fees for scheduled activities in Japan
For the Pre-Departure Orientation and Formation Program, travel expenses within the ' Philippines from their residence (province) to Manila (NAIA) and back shall be charged
against Their locatl funds, MOOE. Board and lodging, and meals for the qualified student and teacher delegates shall be charged against 2017 CO-GAS funds, all subject to the ugual accounting and auditing rules and regulations.
Please note -that no cash allowance is provided to the parfcteipanrts. Participant's shall- pay their personal expenses, including passport fee, and purchasing «$U¥e«k« or personal -goods before -or-during the program.
Office of the Undersecretary for Administration(Administrative Services, Information and Communications Technology, Jjisastfir Misk Jlejtiuetiauaud Management,
Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City
Room 519, Mafami Bttfldmg; Mobile: +63*>26632©762; Landiine: “K3326337203, +0326376207 Email: usee.admirK«dcpod.gov.ph; Face book/Twitter (wdepedtayo
&ejHUjUkang $iUimv36
Eagatoaran ng €imka&$mTanggapan ng Pangalawang Kalihim
E. Application Procedures
Step 1:
1.
Ision Level
3.
4.
The Division Office (DO) through the School Governance and Operations Division (3G0DJ shall receive the .application of interested students, avtd teacher participants from the schools.The Project Hevelapmeni Officer 2 You-fch Formation Coordinate) shall be the focal person for the JENESYS 2017 receipt of applications in the division level. The YFC shall also facilitate the creation of -the division level JENESYS 2017 Screening Committee and conduct an evaluation and interview of applicants.The division level JENESYS 2017 Screening Committee shall ensure that .the applicants have met and completed all the documentary requirements needed.The DO shall forward to the Regional Office the shortlisted applicants to the program.
Step 2: Regional Level
1. After receiving the JENESYS 2017 nominations from the division offices, each Regional Office tRO) through the Education Support Services Division (ESSD) must conduct a regional screening and must submit to the Central Office (CO) a total of six (6) nominees for both programs.
Program MaleStudent
FemaleStudent
Supervisor
Rugby Exchange 1 1 1Language and
.Exchange ,1 1 1
TOTAL 2 2 2
2\ The shortlisted applicants should scan the application documents and save• • It into one (1) PDF Ble in at least 300 dpi resolution.
3. The RO must submit to the Central Office the rearmed document requirements in PDF file on or before the application deadline of each program.
. -(Please see Table 1: Important Requirements and Deadlines)
4. Each nominee should forward an advance soft -copy to:blss.vfd@deped. eov.ph with subject heading:
Office of the Undersecretary for Administration(Administrative Services, Information afH C&rrmmnwmitms Technology, Disaster Risk Reduction and Management,
Schools Health, Youth Formation, Baguio Teachers'Camp, Education Facilities/ School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City
Room 519, Mabini Building; Mobile: +639260320762; Landiine: +6326337203, +6326376207 Email: [email protected]; Face book/Twitter @depcdt ayo
&fpublifcfl ng JJiUpmiiS
l&agatoaraii ng CbufeagponTanggapan ng Pangalawang Kalihim
LASTNAME_REGION_SCHOOL_JENESYS2017 (ex. DELA CRUZ_RBGION 1_JUAN G. MACARAEG NHS_JENESYS2017)
5. The shortlisted applicants per region must submit to the CO their original and scanned application documents on or before August 25. 2017 (for Rugby Sports Exchange program} and on or before September 29. 2017 (for Japanese Language Communication/Exchange in Japanese Culture program). Scanned documents must be sent via e-mail at [email protected].
Step 3: National Level1. The Central Office through the Youth Formation Division (YFD) will
review the applications and conduct the national screening and interview.
2. The YFD will deliberate and provide the list of official Philippine delegates to the.JENESYS 2017 program.
F. Timeline of Activities
E. 1 For Ruehv Exchange Program
Activity DateApfltUcattea Period AllfOisJt 7-1.0, 2017
Application Deadline August 11, 2017IpvaI August 16-18, 2017
Regional level Screening August 21-23, 2017Subsa&skm of the Regional Office’s
consolidated list of nominees to •Central <Qfik>e
August 25, 2017
National Screening and Interview August 30-September 1, 2017Announcement ofthe fimd Philippine
DelegationSeptember 4, 2017
Pre-Departure Orientation and Formation Program
October 7-9, 2017
• l^ugby Youth Exchange Program In Japan
October 10-17, 2017
Office of the Undersecretary for Administration(Administrative Services, Information and Communications Technology, DisasterRisk Reduction and hlanagenwntf
Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City
Room 3*9, Mabirri Bmkitng; Mobile:*63926©33©?6f; Landlme: *63f6337f03, *6326376207 Email: usee. admin@dcped .gov. ph; Faccbook/Twitter @depedtayo
JkimUliUa ng ffiilipiwag
Eagataaran ng €bukas|>0 JiTanggapan ng Pangalawang Kalihim
B.2 For Japanese Language Communication/Exchange in Japanese Culture Program
Activity PafaiApplication Period September 4-6, 2017
AppHpflflfow rUflrillna September 8, 2017Division level Screening September 18-20, 2017Regional Jewel Screening September 25-27,2017
Submission of the Regional Office's consolidated Hat o f nominees to
Central Office
September 29, 2017
National Screening-and Interview October 4-6, 2017Announcement of the final Philippine
DelegationOctober 10, 2017
Pre-Departure Orientation and Formation Program
November 11-13, 2017
Japanese Language Communication/Exchange in Japanese
Culture in Japan
November 14-21. 2017
For inquiries, all concerned may contact Ms. Jen Pascua of the Youth Formation 'Division at (02) 637-9814, or e-mail at biss.vfdftldeped.gov. ph [email protected] with the subject heading: Query: JENESYS 2017.
•. For immediate dissemination and appropriate action.
Attachments:1. J®NES¥S 201T Application Form2. VISA Application Form
Office of the Undersecretary for Administration(AdmniSirjaUmSemms, InforniaUon and Communications Technology, Disast&r Risk Reduction and Management,
Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City
Room 5W/mat>ini3uMing; Mobile: +630260320762; Landline; +6326337203, +6326376207 Email: [email protected],ph; Facebook/Twitter@depedtayo
,4 E S Y S 2 0 1 7Entry Form 2017
p*
(fU\
Program Title ( Your Country ( )
* Read amJ confmn Qtmllffcatlons forT’articipants in the Application Guidelines for JENESYS2017 before filling out this Entry Form.* Refer, to the Sample and Fill in All the relevant Columns and Sections. Blank Columns are Not Accepted.
1. Personal Information
Photo (taken within 3
months} Ploase write
your name on thtrback of your
photo.
Name
'
Pu?j Name (Exactly the sambas YourBasspoEt)English
Full Name (in Mother Language) {Nickname (English)_ | (the name you like to be called)
Date of BirthDay/IVkmth/Year
/ / Age
Nationality Sex r m r f
Marital Status r Single r Married r Widowed r Divorced
Religionr Buddhist r Christian
TQUicr - (
P Muslim r Hindu r No Religion
Mother Tongue
Number
Passport If you nave no passport, ieavemis section ^ank.
Type of Passport
r Private r Diplomat P Official
Date of issueOayMonfh/Year
/ /
Date of£\pjryDay/Month/Year
V /Facebook Twitter lnstac?ram others
Social Media User Account(s)
3K Your postings may be used in the program reports or website which will be open to the public.
Current Address / Phone Number
Address :
Terl : Mobile :
£-urail ;
5K Your E-mail will be sent notices or requests from JICE or Japanese gpvernrnent after the progracn.
Contact Person in case of Emergency
#!t should be your parent.
Full Name_
Reljfijttjpja&tiip : r P Father P Other
Address :
Tel :
E-mail :
Mobile
•If you have no phone at your address, wrlto a
contact*phone number.
Contact Phone Number {Holder's Name i Holder's E-mail
Entry Form 2017 Pag* 1
4 Fill in AH the Columns anri&l^tians* BiankCoiumi*s me MotAeoepfed.
Health Cfloditlon
*
r Good (Noilang to Declare Below)
P i Have Been Diagnosed (Serious Disease)
Name of Disease ; ( ) P fully recovered f under treatment
P Having Chronic Disease
r Chronic lung disease (aslhma, chronic obstructive Jung disease etc,)T Immunodeficiency state (T ceil immunodeficiency etc.) r Chronic heart disease (congenital heart disease, coronary artery disease etc.)
P Metabolic disease (diabetes) P renal dysfunction P obesity r myasthenia gravis
P Others ► ( )
Mediciner Not Taking Any#Medici«e
r Taking Medicine Regularly -> Name of Medicine: ( )
| Pregnancy r No P Yes —> Stop the Entry Form and consult with Focal Point or Japanese Embassy
Physical Difficultyr No PYtes <■
— If Yes, What Difficulty ? { )
F ;od Allergies (only for physical
I reason)
r none
r pork r beef r chicken P mutton/lamb P shrimp Pcrab r shelifis
rfish r e g g Pothers ( )
FimdResMcUcMi (for religious or custom reason)
a 'Check items oven If you n are punt vogotarian,
P m mP pork P beef P chicken P mutton/lamb P shrim P crab P shellfis •
P fish P egg Pothers —* ( )
% Meals during the program may not meet all the requests or restrictions.
Other Allergies or
P none
Physical Reason: P dogs P cats P house dust ‘~ other (<• ) Religious/Custom Reason: P dogs P cats P house dust Pother — ( )
1 SiwtomgHiibKr No PYes
•)K Smoking under 20 is prohibited in Japan. This information may be used for homestay arrangement.
* Fill in AH the Columns and Sections. Blank Columns are Not Accepted.3, School /Company /OrganizationfasamEsaaaBB«gafesss==nsfaaBB9aBBs
Are you Student or Workimj Youth ?
r Graduate Student P University / College Student r High School / Vocational / Other School Student
P Working Youth P Working Student
School
Working student needs to fill in this part.
Name of School
Field of Study or Name o f Fa^iiUy / Department
Grade / School Year: j
Job Title (for supervisor):!
Loca|Hon (City or Prqytnco)
Company / *. ‘ Organization
Wotl - gstudenineecte to ;itl in this part.
Name o f Company / Organization jLocrtion (City or Province)
Department / Division (Qff|(:e_...... ........... ............ _ ......
Job Title:
;language
Official English Test (If any) ; r TOEFL (score: ) j r TOEIC (score: )
r IELTS (score: ) j f * Other - ( )(score: )
Level o f English
Speaking :P Good P Far P Poor
Writing :P Good P Fair P Poor
Reading :P Good P Fair P Poor
Level o f Japanese
Speaking ; P Good P Fair P Poor
Writing I Sood r Fair P Poor
Reading : P ^ood P Fair P Poor
Have ycui j d i ^ anything mlated to Japan or SJapanese? | 1 Yes r N°
Ex. Japanese Stuffy, Resarcb, Business, Cullurc I
Japanese lYear(s), / Month(s) Learning I
Experience]
E«tcyt:am i2tt1V P » * « 2
* Fill in All the Columns and Sections. Bianfc Ca3toins are Wot Accepted.Visiting Japan
lj Have you been to Japan before? r Yes i r Np. — ao need to fill in beiow.
If Yes, how long did you stay in Japan?
r More than 3 months
- * Stop the Entry Form and consult with Focal Point o r Japanese Embassy
r 3 months or less
If Yes, did you join any o f the following?
r JENESYS / KI2UNA r SSEAYP f~ JICA T MEXT
t j f r jN T O t h id a
Stop the Entry Form and consult with Focal Point or Japanese fipafaa&sy
r None of the above
5. Personal Activiities VI Sports/Clubs How Many Years ? { year(s))
Hobbies/Favorites_ . .............................................. ................. _ _ ..._ .............. .....................
Prizes/Awards (Sports or Academic,
if any)!-M0wui.?k< i
’ J
6. Expectations
What Do You Expect in IbisProgwwn ?
A(Write Your Wish, Hope
or Desire for the Program in Relation to Your
Specific. Study, Woik or Experience,)
Declaration (P lease sign 1 and 2. If the applicant is under 18, parent or guardian needs to sign 3.)
1. I hereby certify that th£ filling in and statements in this form have been made by m yself and are true and correc t
Signature: : •______________________________ Date: / / (Day/Month/Year)
2. I have read and agree to all the Qualifications for Participants, Terms and Conditions and the Handling o f Personal Information in the '^ftRiilicajUonfiwifeliaes^for JEMESYS2017.
* ' 1 ».
Signature: _____________________:______________ ,Date: / I (Day/Month/Year)
3. (Pg rt>nt/6uardian) (assure everybodyconcemed that the declaration above is true and correct
Signature: ___________________________________ Date: / / (Day/Month/Year)
Entry Form 2017-Page 3
J E N E S Y S 20 i7 Entry Form 2017Program MumJaer ( Composite 1st
Your Country ( Japan )
* Read and confirm Qualifications for Participants In the Application Guidelines for JENESYS2017 b^fore fni(ng out thi« €ntfy Form.* Refer to the SamploandFiilinAll tfwTetevant^oiumns and Sections, Blank Columns are Not Accepted.
1. Personal Information
m* *■» #«V Vk AName
Futf Name (Exactly the same as Your Passport)English ~~
Naomi Christine Yamada
Name (in Mother Language) Nickname (English)(the clause ^qu Jike to be-eated)
Chris
Date o f BirthDay/Month/Year
25/7/1992 Age 25
Nationality
Marital Status
Japanese S bx xmSingle □Married □Widowed □Divorced
Religion□Buddhist QChristian vQMuslim
□Other — (
□Hindu DNo Religion
)Mother Tongue jlapaoese
Number
Passport If you have no passport, ie^ve thtesefiiifln blank.
jfM234serDate o f issue
Day/Month/Year
15/3/2015
Type o f Passport
Private □ Diplomat DOfficial
Date of E m iryDay/Month/Year
15/3/2025
Social Media User Actjourrtfs)
(on a voluntary basis)
n^omi.yamada
Twitter Instagram
naomin
others
Your postmgsmay be used in the program report or website which will be open to the public.
Current Address / Phone Number
Address : 2-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo* 16^-07i6Japan
Tel : 03-6838-2730 Mobile : 080-1234-5678
E-mail: [email protected]
Contact Person in case of Emergency
'It should be your parent.
;Fyll Name
‘ *: Ken Robert Yamada
Relationship : OMotherVQFather DOther (
Address : a^-I.NishUShmjuku.Shmjtiku-ku,Tokyo, 183-0716Japan
Tel : 03-6838-2730 Mobile : 490^.12*3456
E-mail : [email protected]
*lf you have no phone at your address, write a
contact phone number.
Contact Phone Number ]Holder!s.Name : Holders €-mall
Entry Form 2017 Pago I
1
s
Health Condition
r-^Tj V '-' N 0 f;
* F iilju A U th e C o lu m n s a « d S e c tio n s .B la n k C o lu m n s a r e W ot A c c e p te d .
Health Conditionu *
0t5ood (Nothing to Declare Below) j
□ 1+teveBtjenDiagnosed(SeriousDisease)
Name of Disease: — Ofully recovered Bjunder tceafcaent Q H a v in g Chronic Disease
— OChronic lung disease (asthma, chronic obstructive lung disease etc.)CHmmunocteft^^ ceil immunodeficiency etc.)□Chronic heart disease (congenital heart disease, coronary artery disease etc.)□MeJabi5licifeease (diabetes) Qfanafdysfunetion Oobesity □ myasthenia gravis □Others — * ( )
IWedtcine €lHot T a k i^ Aoy
□Taking Medicine Regularly -* Name of Medicine: ( )
Pregnancy t?No T3 Yes Stop the Entry Form and consult with Focal Point or Japanese Embassy
fHiysicallM fRculty ;fefNo OYas
If Yes, What Difficulty ? ( )
Food A U a r§ ie «| (only for physical 1 reason}
m m m□pork Qbeef □chicken □mutton/lamb Oshrimp Dcrab □shellfish □fish © egg Pothers — ( )
Food Restriction ^foreelktfetts or custom reason)
*Chfick items even if you are pti’ft vegetarian.
□none'Bpork Qbeef Ochicken tDmutton/lamb Oshrimp □crab □shellfish
□fish Oegg □others -* ( )
♦X*Meals during the program may not meet ail the requests or restrictions.
GtherAltergies or Restrictions
□nonePhysical Reason: Qdogs Scats □ house dust □others — ( )
Religious or Custom ReasoMUdogs Qcats JQhause*dust □others —* ( " ’ )
I Smoking Habit© N o DYes$&Smoking under 20 is prohibited in Japan. This information may be u s^ ffir homes^y arrangement.
* Fill in All the Columns and Sections. Blank C oiiim n^^B ^U ^^cap^d .
1— ™ ------------- -Ata youJ&tudentor
Working Youth ?
□Graduate Student □ University / College Student DHigh School / Vocational /<Dthtsr School Sludent
□Working Youth M3vVorking Student
S ch oo l ,
V OffciagjstMcient neadsio (it! in this pari.
Name o f School
.. JapanMetoatiofiaJJ^
Field o f Study or Name o f Faculty I Department
Accounting■(jifaur/atfnooi '** ..* ' »
... ......... . ...,......— .......... ......... .................................. 2nd>Job Tide (for supervisor):
Location (City or Province)
Tokyo
roar
Company/ Organization .
»*
Working student needs to ’ fill in this part.
Name of Company / Organization
, ? ABC International Co., Ltd.
Department / Division / Officer International Investment Dii
Job Tnie: AssistantlVlanager
Locator (City or Pjxwoace)
Tokyo
vision
Language
Official English Test (If any) WTOEFL (score: 100 ) ^BTOEIC (score: 748 )OIELTS (score: ) DOther ( )(score: )
_________ Level o f Engjish _Speaking : QGood ^^JFair DPoor Writing :<€3Good QFair DPoor feeding r^ S ood OFair DPoor
Level o f Japanese Speaking: □Good \0Fair DPoor Writing : DGood OFair «v3Poor Reading : QGood □Fair M O Poor I
Have you done anything related to Japan i^Japanese? j ™ o
Ek. Japai»cse Study, Rosarch. Business, Culturo \
Japanese iYear(s)/Month(s)^Learning ; s month*Experience i
Entry Form 2017 Page 2
•Partner’s profession/occupation (or that ofpargn]^.if applicantisa,minor):
fiUagim prXtf Eefet6RCein Jdp&f1(Please provide delaBs of the guarantor or the person to be visited in Japan)
Name____________________ Tel.____________________________________________________
Address _____________________________________________________
Date of birth ______________ Sex: Male Q Female Q(Day)/(Morirfijy|Vear)
Relationship to applicant ________________________________________________
Professtanor occupation and position___________________________________________
Nationality and immigration.status______________________________________________
Inviter in JapanjPlease write 'same as above' if the inviting person and the guarantor are the same)
Name ______________________ ____________________________________ Tel.______
Address __________________________________________________________ _
Date o f birth_________________ Sex: Male □ Female Q(Dny}/(Month)/(Ycar)
RelaliaDshlpjtoappHcacvt__________________________________________________
Profession or occupation and position _____________________________
Nationality and immigration status_______________________ ________________ _
# errwte/5pecferl circumstances/if any_________________________________________ _Have you ever:• been convicted of a crime or offence in any country?• been sentenced to imprisonmmJt for I y e a r c o u n t r y ? * *m been deported or removed from Japan or any country for overstaying your visa or violating
any Jaw or regulation?• been convicted and sentenced for a drug offence in any country in violation of law
concerning narcofematfjuana,Qpium, stimulants or-psych tropic substances?**• engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
persons, or in Jdte^OMisiao*afa piace-for prostitution, or any other activity directly connected to prostitution?
• committed*traffickingjn^»^^ici€i^^alded^d#ieriot!ommrtsuch an offence?, ** please tick ‘'Yes" if you have received any sentence, even if the sentence was suspended.
If you answered “Yes" to any of the above questions, please provide relevant details.
1 hereby ik c t e thdtlbe statement given abovetsirue andcorrect! understand that immigration status and period of stay to be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not entitle the bearer to enter Japan upon arrival at port of entry if he qr she isiQund.inadmissibte.-'Thereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the J^aneseembassy/consulate-generalwhen such paymenris necessary.*
Date of application_______________________ Signature of a p p l ic a n t ____________________________________{Oay)/{Month)/CYear} “
* It is not mandatory to complete these items.
Any personal information gathered in this application as well as additional information submitted for the visa application (hereinafter referred to as "Retained P csonal lnformation") will he handW^ppropf iately in accordance with the Act on the Protection of Personal Information Held by Administrative Organs (Act No. 58 o f2003, hereinafter, "the Act"). Retained Personal Information will only be used for the purpose of processing the visa application and to the extent necessary for the pwrposes statedinAfttcleS tjfthe Act.
* * □ NoQ
VesQ NoQ
noQ
VesQ N oQ
V« DY « Q noQ
Visiting Japan 44aveyotrbeen to Japan before?
‘ Fill in AH the Columns and Sections. Blank Columns are Not Accepted.
If Yes, hov long did you stay in Japan?
if Yes, <Mytm jtrmany of the following?
*0Yes J □M o no need to fill in below.
□roowthan 3 months -* Stop the Entry Form and consult with Focal Point or Japanese .Embassy
£2*3 months or less
□JENESYS I KIZUNA □SSEAYP □ JICA OMEXT OJF OJNTO OHIDA
♦ Stop the Entry Form and consult with Focal Point or Japanese Embassy
<€?None of the above
5. Personal ActivitiesI Sports/Clubs Athletic Club How Many Years ? ( 5 year(s))
I H obt^/favorKes Travel, Reading (Harry Potter), Animation (One Piece)
■Prizes/Awards
(Sports or Academic, if a ny )
1st Prize, Tokyo Field Competition, ^ A , High School Female Fast Run 100m -W h e n ? ( 0ctobcr2008 )
6. Fxpftntations
WfcatDe You Expect4 in This Program ?
(Write Your Wish. Hope or Desire fo. vhe Program
in Reladon to Your Specific Study, Work
or Experience.)
r,r , m T . _ ^OOOOOOODDDOOCOOOOOOOOOOOOOOOOOOOooooooooooooooooooooooooooooooooOOOOOOOOOOOOOOOOOOOOOOOOOOODQOOD
Declaration (Please sign 1 and 2. If the applicant is under 18j j>arent or guattlianneedstesigfi 3.)
1. I hereby certify that the'tilling in and statements in this form have been made by myseif and are true and correct.
Signature: jL Date: IS / 8 / 2017 (Pav/Month/Yeart
2. I have read and agree’to all the Qualifications for Participants, Terms and Conditions and the Handling af Persocial infocooatiou in the AppUcakksn Guidelines for JENESYS2017.
Signature: Date: IS / 8 I 2017 (Dav/Month/Year)
3. (Parent/Guardian) I asaure everybocfy conGemed lhatthe dectBfation above is true and correct.
Signature: Date: I I (Dav/Month/Year)
Entry Form 2017 P**e 3
•Official use only
(Paste photo here)
45mm x45mm
or 2inx2in
Surnaraejassbownm passport)___________
Given and middle names (as shown in passport)
Other names (including any other names you are or have been known by)
Date of birth______ ______ Place of birth_____________________________________________________iwlbMH)/| Veai) (City) (State or Province) (Country)
Sex: Male LJ Female 0 Marital status: Single Q Married Q Widowed Q Divorced Q
Nationality or citizenship______________________________________________________________________
-Pocmer and/or other nationalities or citizenships ___________________________ _______________
ID No. issued toyou by your government________________________________________
Passport type: Diplomatic □ Official Q Ordinary Q Other Q
Passport No. ________________________________________________
Place ofresue ________________________________________________ Date of issue_______________fDay)/(Month)/(Vear}
Issuinq authority Date of expiry(bayWMonth)/!Yeari
Purpose of visit to Japan______________________ _______________________________________________
Intended length of stay in Japan_____________________________________________________________
•Date of arrival in Japan________________________ _______ ______________________________ _■*Port of entry into Japan_______________________ Name of-shtp or airline___________________________
Names and addresses of hotels or persons with whom applicant intends to stay
' Name Tel.
Address
Dates and duration of previous stays in Japan_______________________________________
Your current residential address (if you have more than one address, please list them all)
Address ________
Tel. Mobile No.
Current profession or ocoyaation im position_____________________________ __
Name and address of employer
Name Tel.
Address
•Partner's profession/occupation for that of parents, if applicant is a minor):
Guarantor or reference in JapanfPiesse provide details of the guarantor or the person to be visited In Japan)
Name___________________ Tel,
Address
Date of birth_____ _______ Sex: Male □ Female □(Day)/(7th)/{Ve3rjRelationship to applicant_________________ _________ _____________
Profession or occupation and position^
Nationality and immigration status___
In Viter in Jap3n{Please write ‘same as above* If the invitfng person and the guarantor are the same)
Name_________________________ ____________ _____ _______________ Tel.^
Address
Date of birth________ Sex: Male □ Female □{Oayj/(Wonthy/(Year)
Relationship to applicant_______________
Profession or occupation and position____________________________________________
Nationality and Immigration status____________________ ___________ ____________
^Remarks/Special circumstances, if any__________________ ____________________
Have you ever:• been convicted of a crime or offence in any country?
• been sentenced to imprisonment for 1 year or more in any country?**
• been deported or removed from Japan or any country for overstaying your visa or violating any law or regulation?
• been convicted and sentenced for a drug offence in any country in violation of law concerning narcotics* marijuana, opium, stimulants or psychotropic substances?**
• engaged in prostitution* or in the intermediation or solicitation of a prostitute for other persons, or in the provision of a place for prostitution, or any other activity directly connected to prostitution?
• committedtraffkking in persons or incited or aided another to commit such an offence?
** Please tick "Yes* if you have received any sentence, even if the sentence was suspended.
if you answered "Yes” to any of the above questions, please provide relevant details.
YesD N o Q
NoQ
N ° D
YcsQ NoQ
NoQ
V esQ HoQ
1 hereby declare that the statement given above is true and correct. I understand that immigration status and period of stay to be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not entitle the bearer to enter Japan upon arrival at port of entry if he or she is found inadmissible."1 hereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the Japanese embassy/consulate-general, when such payment is necessary.*
Date of application______________________ Signature of applicant ____ _________________________{Oay)/(Month)/{Year}
* It is not mandatory to complete these items.
Any personal information gathered in this application as well as additional information submitted for the visa application (hereinafter referred to as “Retained Personal Information'') will be handled appropriately in accordance with the Act on the Protection of Personal Information Held by Administrative Organs ( Act No. 58 of 2003, hereinafter, "the Act"), Retained Personal Information will only be used for the purpose of processing the visa application and to the extent necessary for the purposes stated in Article 8 of the Act.