Training 1506

8/19/2019 Training 1506

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CONFIDENTIAL

Versi: June , 2015

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ENGLISH

8/19/2019 Training 1506


8/19/2019 Training 1506


CONFIDENTIAL

Versi: June , 2015

Guidelines of Application Form for

the JICA Knowlede Co!Creation "roram

he atta+he orm is to *e use to appl& or the Kno%lege Co)Creation program !KCCP"

o the Japan International Cooperation Agen+& !JICA", %hi+h are implemente as part o

the 4i+ial #e3elopment Assistan+e Program o the o3ernment o Japan- Please

+omplete the appli+ation orm %hile reerring to the ollo%ing an +onsult %ith the

respe+ti3e +ountr&6s JICA 4i+e ) or the 7m*ass& o Japan i the ormer is not a3aila*le ) in

&our +ountr& or urther inormation-

#$ "arts of Application Form to %e completed

#& 'hich part of the form should %e su%mitted(

It epens on the t&pe o KCCP &ou are appl&ing or-

)Application for KCC" *Group and +eion Focus&

4i+ial appli+ation an Parts A an ( in+luing 'ei+al 8istor& must *e su*mitte-

))Application for KCC" *Countr, Focus& includin KCC" for Counterpart and KCC"

related to ODA Loan

4i+ial Appli+ation an Part ( in+luing 'ei+al 8istor& %ill *e su*mitte- Part A nees not

to *e su*mitte-

-& .ow man, parts does the Application Form consist of(he Appli+ation Form +onsists o three parts as ollo%s9

Official Application

his part is to *e +onirme an signe *& the hea o the rele3ant epartment/i3ision o

the organiation %hi+h is appl&ing-

"art A$ Information on the Appl,in Orani/ation

his part is to *e +onirme *& the hea o the rele3ant epartment/i3ision o the

organiation %hi+h is appl&ing-

"art 0$ Information A%out the Nominee includin 1edical .istor,his part is to *e +omplete *& the person %ho is nominate *& the organiation appl&ing-

he appli+ants or KCCP !roup an $egion Fo+us" are reuire to ill in e2er, item- As

or the appli+ations or KCCP !Countr& Fo+us" in+luing KCCP or Counterpart an some

spe+iie programs, it is reuire to ill in the esignate 3re4uired5 items as is sho%n on

the Form-

Please reer to the eneral Inormation to in out %hi+h t&pe KCCP that &our organiation

applies or *elongs to-

-$ .ow to complete the Application Form

In +ompleting the appli+ation orm, please *e a3ise to:!a" +areull& rea the eneral Inormation !I" or %hi+h &ou inten to appl&, an +onirm i

the o*.e+ti3es an +ontents are rele3ant to &ours,

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!*" *e sure to %rite in the title name o KCCP a++uratel& a++oring to the I, %hi+h &ou

inten to appl&,

!+" use a t&pe%riter/personal +omputer in +ompleting the orm or %rite in %loc6 letters,

!" ill in the orm in Enlish,

!e" use or ;<= to ill in the ! " +he+k *o<es,

!" atta+h a pi+ture o the >ominee,

!g" atta+h aitional page!s" i there is insui+ient spa+e on the orm,

!h" prepare the ne+essar& o+ument!s" es+ri*e in the eneral Inormation !I", an

atta+h it !them" to the orm,

!i" +onirm the appli+ation pro+eure stipulate *& &our go3ernment, an

!." su*mit the original appli+ation orm %ith the ne+essar& o+ument!s" to the responsi*le

organiation o &our go3ernment a++oring to the appli+ation pro+eure-

An& inormation that is a+uire through the a+ti3ities o the Japan International

Cooperation Agen+& !JICA", su+h as the nominee6s name, eu+ational re+or, an mei+al

histor&, shall *e properl& hanle in 3ie% o the importan+e o saeguaring personal

inormation-

7$ "ri2ac, "olic,

#& 8cope of 9se

An& inormation use or ienti&ing ini3iuals that is a+uire *& JICA %ill *e store, use,

or anal&e onl& %ithin the s+ope o JICA a+ti3ities- JICA reser3es the right to use su+h

ienti&ing inormation an other materials in a++oran+e %ith the pro3isions o this pri3a+&

poli+&-

-& Limitations on 9se and "ro2ision

JICA shall ne3er intentionall& pro3ie inormation that +an *e use to ienti& ini3iuals to

an& thir part&, %ith the ollo%ing three e<+eptions:

!a" In +ases o legall& manate is+losure reuests9

!*" In +ases in %hi+h the pro3ier o inormation grants permission or its is+losure to a

thir part&9

!+" In +ases in %hi+h JICA +ommissions a part& to pro+ess the inormation +olle+te9 the

inormation pro3ie %ill *e %ithin the s+ope o the +ommissione tasks-

7& 8ecurit, Notice

JICA takes measures reuire to pre3ent leakage, loss, or estru+tion o a+uire

inormation, an to other%ise properl& manage su+h inormation-

:$ Cop,riht polic,

Parti+ipants o KCCP are reueste to +ompl& %ith the ollo%ing +op&right poli+&9

Arti+le 1- Complian+e matters %ith parti+ipants6 rating o o+uments !3arious reports,

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a+tion plans, et+-" an presentations !report meetings, le+tures, spee+hes, et+-"

1- An& +ontents o the o+uments an presentations shall *e +reate *& themsel3es in

prin+iple-

2- Compl& %ith the ollo%ing matters, i &ou, o3er the limit o uotation, ha3e to use a thir

person6s %ork !reprou+tion, photograph, illustration, map, igure, et+-" that is prote+te

uner la%s or regulations in &our +ountr& or +op&right)relate multinational agreements or

the like:

!1" 4*tain li+ense to use the %ork on &our o%n responsi*ilit&- In this +ase, the s+ope o the

li+ense shall meet the pro3isions o Arti+le 2-

!2" ?e+ure e3iential material that pro3es the grants o the li+ense an spe+iies the s+opeo the li+ense-

!@" Consult %ith the thir part& an perorm the pa&ment pro+eure on &our o%n

responsi*ilit& regaring negotiations %ith a thir person a*out the +onsieration or granting

the li+ense an the pro+eure or pa&ing the +onsieration-

Arti+le 2- #etails o use o %orks use or KCCP

!1" he +op&right on a %ork that a parti+ipant prepares or KCCP shall *elong to the

parti+ipant- he +op&right on the parts %here a thir part&6s %ork is use shall *elong to the

thir part&-

!2" hen using te<ts, supplementar& eu+ational materials an other materials istri*uteor KCCP, parti+ipants shall +ompl& %ith the purposes an s+opes appro3e *& ea+h

+op&right holer-

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Kno%lege Co)Creation Program uner e+hni+al Cooperation %ith the o3ernment o Japan

Application Form for the JICA Knowlede Co!Creation "roram

OFFICIAL A""LICATION

!to *e +onirme an signe *& the hea o the rele3ant epartment / i3ision o the appl&ing organiation"

#$ Title; !Please %rite o%n as sho%n in the eneral Inormation!I""

-$ Num%er; !Please %rite o%n as sho%n in the eneral Inormation! I""

J !

7$ Countr, Name;

:$ Name of Appl,in Orani/ation;

<$ Name of the Nominee*s&;

1" @"

2" B"

IN8TIT9TION=DI>I8ION

4ur organiation here*& applies or Kno%lege Co)Creation program !KCCP" o the JapanInternational Cooperation Agen+& an proposes to ispat+h ualiie nominees to parti+ipate in

the programs-

#ate: ?ignature:

>ame:

#esignation / Position 4i+ial ?tamp

#epartment / #i3ision

4i+e Aress an

Conta+t Inormation

Aress:

elephone: Fa<: 7)mail:

1INI8T+? *'hen this application is throuh a ministr,$&

4ur ministr& here*& applies or the training an ialogue program o the Japan International

Cooperation Agen+& an proposes to ispat+h ualiie nominees to parti+ipate in the

programs-

#ate: ?ignature:

>ame: 4i+ial ?tamp

#esignation / Position


1INI8T+? OF 8TATE 8EC+ETA+IATI ha3e e<amine the o+uments in this orm an oun them true- A++oringl& I agree to

nominate this person!s" on *ehal o our go3ernment-

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#ate: ?ignature:

>ame: 4i+ial ?tamp

#esignation / Position


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"art A; Information on the Appl,in Orani/ation!to *e +onirme *& the hea o the epartment / i3ision"

A$#$ "rofile of Orani/ation

A$#$ #& Name of Orani/ation;

A. #$ -& The mission of the Orani/ation and the Department = Di2ision;

A$-$ "urpose of Application

A$-$#& Current Issues; Descri%e the reasons for ,our orani/ation claimin the need to

participate in Knowlede Co!Creation "roram *KCC"&@ with reference to issues or

pro%lems to %e addressed$

A$-$-& O%ecti2e; Descri%e what ,our orani/ation intends to achie2e %, participatin in

KCC"$

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A$-$7& Future "lan of Actions; Descri%e how ,our orani/ation shall ma6e use of the

eBpected achie2ements@ in addressin the said issues or pro%lems$

A$-$:& 8election of the Nominee; Descri%e the reason*s& the nominee has %een selected

for the said purpose@ referrin to the followin 2iew points #& Course re4uirement@ -&

Capacit, ="osition@ 7& "lans for the candidate after the KCC"@ :& "lan of orani/ation andA$-$<& Others$

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"art 0; Information a%out the Nominee!to *e +omplete *& the >ominee"

>47he appli+ants or Kno%lege Co)Creation Program !KCCP" !roup an $egion Fo+us" are reuire to ill in

;73er& Item=- As or the appli+ations or KCCP !Countr& Fo+us" in+luing KCCP or Counterpart an some spe+iie

programs, it is reuire to ill in the esignate 3re4uired5 items as is sho%n *elo%-

0$#$ Title; !Please %rite o%n as sho%n in the eneral Inormation" *re4uired&

0$-$ Num%er ; !Please %rite o%n as sho%n in the eneral Inormation" *re4uired&

J !

0$7$ Information a%out the Nominee *nos$ #! are all re4uired&

0$ 7$ #& Name of Nominee *as in the passport& name

Famil, Name

First Name

1iddle Name

0$7$-& Nationalit,

*as shown in the passport&

0$7$<& Date of 0irth *please write out

the month in Enlish as in 3April5&

0$7$7& 8eB ! " 'ale ! " Female Date 1onth ?ear Ae

0$7$:& +eliion

0$7$& "resent "osition and Current Duties

4rganiation


Present Position

#ate o emplo&ment *&

the present organiation

#ate 'onth Year #ate o assignment to the

present position

#ate 'onth Year

0$7$& T,pe of Orani/ation

! " >ational o3ernmental ! " Do+al o3ernmental ! " Pu*li+ 7nterprise

! " Pri3ate !proit" ! " >4/Pri3ate !>on)proit" ! " Eni3ersit&

! " 4ther ! "

10

+ecent "hotoraph

8i/e ; :B

!hite *a+kgroun"

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0$7$& Outline of duties; Descri%e ,our current duties

0$7$& Contact Information

4i+e Aress:

7D: 'o*ile !Cell Phone":

FA: 7)mail:

8ome Aress:


FA: 7)mail:

Conta+t person

in emergen+&

>ame:

$elationship to &ou:

Aress:


FA: 7)mail:

0$7$#H& Others *if necessar,&

0$:$ Career +ecord

0$:$#& Jo% +ecord *After raduation&

4rganiation Cit&/

Countr&

Perio Position or itle (rie Jo* #es+ription

From

'onth/Year

o

'onth/Year

0$:$-& Educational +ecord *.iher Education& *re4uired&

Institution Cit&/

Countr&

Perio #egree o*taine 'a.or

From

'onth/Year

o

'onth/Year

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H I on6t ha3e passport !>ot &et"

0$$ EBpectation on the applied KCC"

0$ $#& "ersonal Goal; Descri%e what ,ou intend to achie2e in the applied KCC" in relation to the

orani/ational purpose descri%ed in "art A!-$

0$$-& +ele2ant EBperience; Descri%e ,our pre2ious 2ocational eBperiences which are hihl,

rele2ant in the themes of the applied KCC"$ *re4uired&

0$$7& Area of Interest; Descri%e ,our su%ect of particular interest with reference to the contents of

the applied KCC"$ *re4uired&

B. $ Declaration *to %e sined %, the Nominee& *re4uired&I +erti& that the statements I ha3e mae in this orm are true an +orre+t to the *est o m& kno%lege-

I a++epte or the program, I agree:

!a" not to *ring or in3ite an& mem*er o m& amil& !e<+ept or a program %hose perio is one &ear or

more",

!*" to +arr& out su+h instru+tions an a*ie *& su+h +onitions as ma& *e stipulate *& *oth the

nominating go3ernment an the Japanese o3ernment regaring the program,

!+" to ollo% the program, an a*ie *& the rules o the institution or esta*lishment that implements sai

program,

!" to rerain rom engaging in politi+al a+ti3it& or an& orm o emplo&ment or proit or gain,

!e" to return to m& home +ountr& at the en o the a+ti3ities in Japan on the esignate light s+heule

arrange *& JICA,

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!" to is+ontinue the program i JICA an the appl&ing organiation agree on an& reason or su+h

is+ontinuation an not to +laim an& +ost or amage ue to the sai is+ontinuation-

!g" to +onsent to %ai3e an& +op&right holer6s rights or o+uments or prou+ts prou+e uring the

pro.e+t, against upli+ation an/or translation *& JICA, as long as the& are use or the purposes o the

program-

!h" to appro3e the pri3a+& poli+& an the +op&right poli+& mentione in the uielines o Appli+ation-

JICA6s Inormation ?e+urit& Poli+& in relation to Personal Inormation Prote+tion

JICA %ill properl& an sael& manage personal inormation +olle+te through this appli+ation orm in

a++oran+e %ith JICA6s pri3a+& poli+& an the rele3ant la%s o Japan +on+erning prote+tion o

personal inormation an take prote+tion measures to pre3ent i3ulgation, loss or amages o su+h

personal inormation-

Enless other%ise o*taine appro3al rom an appli+ant itsel or there are 3ali reasons su+h as

is+losure uner la%s an orinan+es, et+-, an e<+ept or the ollo%ing 1-)@-, JICA %ill neither

pro3ie nor is+lose personal inormation to an& thir part&- JICA %ill use personal inormation

pro3ie onl& or the purposes in the ollo%ing 1-)@ an %ill not use or an& purpose other than the

ollo%ing 1-)@ %ithout prior appro3al o an appli+ant itsel-

1- o pro3ie KCCP to the parti+ipants rom e3eloping +ountries-

2- o pro3ie KCCP to the parti+ipants rom e3eloping +ountries uner the Citiens6 Cooperation

A+ti3ities-

@- In aition to 1- an 2- a*o3e, i the go3ernment o Japan or JICA etermines ne+essar& in the

+ourse o te+hni+al +ooperation-

!i" to o*ser3e Japanese la%s an orinan+es uring m& sta&, i I 3iolate Japanese la%s an orinan+es,

I %ill return the total amount or a part o the e<peniture reuire or the KCCP epening on the e<tent

o the 3iolation-

!." to unerstan that JICA oes not assure issuan+e o Japan entr& 3isa e3en ater JICA e+ie to a++ept

me- I unerstan the 7m*ass& o Japan %ill e+ie it a++oring to ne+essar& ormalities upon the

su*mission o 3isa appli+ation rom ea+h parti+ipant-

#ate: ?ignature:

>ame !&pe out":

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MEDICAL HISTORY/ RIWAYAT MEDIS

1- Present 'ei+al ?tatus/ Konisi 'eis ?aat Ini :

!1-a" #o &ou +urrentl& use an& mei+ine or ha3e regular mei+al +he+kup *& a ph&si+ian

or &our illness/ Apakah sekarang ini Ana seang menggunakan !konsumsi" o*at

atau men.alankan pemeriksaan meis se+ara teratur oleh okter atas pen&akit Ana

H

>o/iak

H Yes/Ya >ame o illness/ >ama pen&akit ! ",

>ame o mei+ine/ >ama o*at ! "

If yes, please attach your doctor's letter (preferably, written in English) that

describes current status of your illness and agreement to join the program/

Jika ya, silahkan melampirkan surat dari dokter anda (sebaiknya, ditulis

dalam bahasa Inggris) yang menjelaskan status/kondisi sekarang mengenai

penyakit nda serta persetujuan dokter yang menjelaskan bahwa anda

dapat mengikuti program ini!

!1-*" Are &ou pregnant /Apakah ana alam keaaan hamil

H

>o/iak

H Yes: 'onths o pregnan+&/ (ulan kehamilan ! months/(ulan"

!1-+" Are &ou allergi+ to an& mei+ation or oo/ Apakah ana alergi terhaap o*at atau

makanan

H

>o/iak

H Yes/Ya- hat are &ou allergi+ to/Ana alergi terhaap apa !

"

!1-" Please ini+ate an& nees arising rom isa*ilities that might ne+essitate aitional

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pem*erhentian se*agai peserta program-

#ate/anggal ?ignature/ ana angan

>ame!&pe out" :/Ketik >ama Ana:

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Training 1506