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Entry Form for JENESYS 2.

0 Programme
(Country:

1. Personal Information

* Please fill in the form in BLOCK LETTE


Full Name (Exactly the same as your passport) (in English)
Name

Photo
(taken within 3
months)
Please write
your name on
the back of your
photo.

Given name (English)

Family Name (English)

Full Name (in Mother language)

(Day)

Date of Birth
(as shown on your
passport)

(Month)

(Year)

Nationality
Religion

Buddhist
Hindu

(
Christian
Muslim

Roman Catholic
Protestant ) Other
(

Others

Mother Tongue

Marital Status
Number

Passport**

Type of Passport

Date of Issue
(Day)

Private

Date of Expiry
(Month)

(Year)

(Day)

Address
Current Address
Tel:

Fax:

Mobile:

E-mail:

Full Name

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

Address

Tel:

Fax:

Mobile:

E-mail:

Profession/Occupation:
Full Name
*If you do not have phone at
your current address, please
write contact person and
number.

Revised on 20/11/2013

*If you do not have phone at


your current address, please
write contact person and
number.

Phone 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.

Revised on 20/11/2013

2. Health Condition
Blood Type

UNKNOWN

AB

Good

Health Condition

Having Chronic disease


Please specify:
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
infectious diseases (Specified:
)
others (
)
1. A permission letter by doctor is required in the pre-departure orientation.
2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

Medicine
Pregnancy
*for women

Not taking any medicines

Taking medicines regularlly (Specified

*Pregnant women cannot participate in JENESYS 2.0 Programme


owing to maternal and child health reason.

Yes No

None
Food Allergies
(which may cause allergic Shrimp Crab
reaction)
Others (

Shellfish

Fish

Egg
)

None
Food Restriction
(for religion or custom
reason)

Pork

Beef

Fish

Egg

Chicken

Mutton/Lamb Shrimp Crab

Others (

Shellfish
)

*Please be noted that the meals provided in the programme cannot meet all the requests from the participan

Dietary
Requirements

None

Other Allergies and


Restriction

None

Vegitarian

Dogs

Halal

Others (

House dust

Others (

Vegan

Cats

3. Academic Details
Name of School / University

Tel:
Information of your
School/University

Fax:

Field of study (for university


student only)
Grade/school year (for student)
as of the day of the flight to Japan

* I confirm that I am a student (possess student ID)


For Supervisor only

Profession/Occupation:
Title
English Proficiency
certificated score (if any, e.g. TOEFL)

Level of English
Speaking :
Language

Good

Level of Japanese
Fair

Poor

Speaking :

Good

Fair

Revised on 20/11/2013

Language

Writing

Good

Fair

Poor

Writing

Good

Fair

Reading :

Good

Fair

Poor

Reading :

Good

Fair

Other Language

Japanese learning
experience

Revised on 20/11/2013

4. Personal Activities
Activities
Sports/Clubs
Hobbies
Academic Awards
(if any)

5. Essay

*Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.

1. Why do you want to


participate in the
JENESYS 2.0
Programme?
2. What will you be able
to contribute to it?

6. Other Information
Have you ever been to Japan before?

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 Programme 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.

Agreement of the Application Guidelines for JENESYS 2.0


I have read and understood the terms and conditions in the "Application guidelines for JENESYS 2.0."

Agreement of the Handling of Personal Information


I agree that my personal information in the Entry Form
will be used in accordance with the Handing of Personal Information (ANNEX).
(Day)

Participant's Signature:

Date:

(Month)

(Year)

Revised on 20/11/2013

For those who are aged under 18, please have your parent's signiture.
For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.
(Day)

Parent's Signature:

Date:

(Month)

(Year)

Revised on 20/11/2013

ANNEX

Revised on 20/11/2013

Revised on 20/11/2013

Reg.No.

ramme

ill in the form in BLOCK LETTERS.

t) (in English)

Middle Name (English) (if any)

Age (as of the


starting day of the
programme)
Sex

Male

Female

Single

Diplomat

(Month)

Married

Official

(Year)

Relationship

Relationship

Revised on 20/11/2013

ease leave the section blank.

Revised on 20/11/2013

etc.)

disease etc.)
myasthenia gravis

he programme insurance.

Programme

ab

Shellfish

ll the requests from the participants.

Location (city,province)

Yes

No

Japanese
:

Good

Fair

Poor
Revised on 20/11/2013

Good

Fair

Poor

Good

Fair

Poor

Year or Month

Revised on 20/11/2013

Period of Involvement

tional pages as needed.

wed to take part again.

to the best of my knowledge.

ENESYS 2.0

elines for JENESYS 2.0."

ormation

m
ion (ANNEX).

(Day)

(Month)

(Year)

Revised on 20/11/2013

agree to his/her participation.

Day)

(Month)

(Year)

Revised on 20/11/2013

Revised on 20/11/2013

Revised on 20/11/2013

Entry Form for JENESYS 2.0 Programme


(Country:

1. Personal Information

* Please fill in the form in BLOCK LETTE


Full Name (Exactly the same as your passport) (in English)

Photo
(taken within 3
months)
Please write
your name on
the back of your
photo.

Name

JAMES JOHN SMITH

Given name (English)

Family Name (English)

JAMES

SMITH

Full Name (in Mother language)

JAMES JOHN SMITH


Date of Birth
(as shown on your
passport)

(Day)

(Month)

(Year)

01

January

1994

Nationality
Religion

AUSTRALIA
Buddhist
Hindu

Roman Catholic
Protestant ) Other
(

Others

(
Christian
Muslim

ENGLISH

Mother Tongue

Marital Status

Number
Passport**

Type of Passport
L1234567

Date of Issue

Private

Date of Expiry

(Day)

(Month)

(Year)

(Day)

01

April

2014

01

Address
Current Address

123 JENESYS ROAD, SYDNEY, NSW 4567, AUSTRALIA


Tel: +61-1-234-567

Fax: +61-1-234-567

Mobile: +61-7-654-321

E-mail: jenesys2.0@cool.japan

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

Address
123 JENESYS ROAD, SYDNEY, NSW 4567, AUSTRALIA
Tel: +61-1-234-567

Fax: +61-1-234-567

Mobile: +61-7-987-654

E-mail: social_community@cool.japa

Profession/Occupation:
Full Name
*If you do not have phone at
your current address, please
write contact person and
number.

Revised on 20/11/2013

*If you do not have phone at


your current address, please
write contact person and
number.

Phone 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.

Revised on 20/11/2013

2. Health Condition
Blood Type

Health Condition

UNKNOWN

AB

Good

Having Chronic disease


Please specify:
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
infectious diseases (Specified:
)
others (
)
1. A permission letter by doctor is required in the pre-departure orientation.
2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

Medicine
Pregnancy

Not
taking any medicines

Taking medicines regularlly (Specified

*Pregnant women cannot participate in JENESYS 2.0 Programme


owing to maternal and child health reason.

Yes No

None
Food Allergies

(which may cause allergic Shrimp


Crab
reaction)
Others (

Shellfish

Fish

Egg
)

None

Food Restriction
(for religion or custom
reason)

Pork

Beef

Fish

Egg

Chicken

Mutton/Lamb Shrimp Crab

Others (

Shellfish
)

*Please be noted that the meals provided in the programme cannot meet all the requests from the participan

Dietary
Requirements
Other Allergies and
Restriction

None

Vegitarian

Halal

Others (

House dust

Others (

Vegan

None
Dogs

Cats

3. Academic Details
Name of School / University
JENESYS2.0 UNIVERSITY
Tel: +61-3-111-222
Information of your
School/University

Fax: +61-3-333-444

Field of study (for university


student only)

COOL JAPAN

Grade/school year (for student)


as of the day of the flight to Japan

SOPHOMORE

* I confirm that I am a student (possess student ID)


For Supervisor only

Profession/Occupation:
Title
English Proficiency

NATIVE

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

Level of English
Speaking :

Good

Level of Japanese
Fair

Poor

Speaking :

Good

Fair

Language
Revised on 20/11/2013

Language

Writing

Good

Fair

Poor

Writing

Good

Fair

Reading :

Good

Fair

Poor

Reading :

Good

Fair

Other Language

JAPANESE

Japanese learning
experience

Revised on 20/11/2013

4. Personal Activities
Activities
Sports/Clubs

FOOTBALL

Hobbies

READING / WATCHING MOVIE

Academic Awards
(if any)

DEAN'S LIST LETTER

5. Essay

*Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.

This is a sample, this is a sample, this is a sample, this is a sample.

1. Why do you want to


participate in the
JENESYS 2.0
Programme?
2. What will you be able
to contribute to it?

6. Other Information
Have you ever been to Japan before?

Yes

No

If Yes, When?

If Yes, what was the purpose of the visit and


Family Trip
where did you visit?
*In principle, any candidates who have participated in JENESYS 2.0 Programme 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.

Agreement of the Application Guidelines for JENESYS 2.0


I have read and understood the terms and conditions in the "Application guidelines for JENESYS 2.0."

Agreement of the Handling of Personal Information


I agree that my personal information in the Entry Form
will be used in accordance with the Handing of Personal Information (ANNEX).
(Day)

Participant's Signature:

Date:

(Month)

(Year)

Revised on 20/11/2013

For those who are aged under 18, please have your parent's signiture.
For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.
(Day)

Parent's Signature:

Date:

(Month)

(Year)

ANNEX

Revised on 20/11/2013

Revised on 20/11/2013

Reg.No.

ramme

ill in the form in BLOCK LETTERS.

t) (in English)

Middle Name (English) (if any)


JOHN

Age (as of the


starting day of the
programme)
Sex

20

Male

Female

Single

Married

Diplomat

Official

(Month)

(Year)

April

2024

-1-234-567

enesys2.0@cool.japan
Relationship
FATHER

-1-234-567

ocial_community@cool.japan

Relationship

Revised on 20/11/2013

ease leave the section blank.

Revised on 20/11/2013

etc.)

disease etc.)
myasthenia gravis

he programme insurance.

Programme

ab

Shellfish

ll the requests from the participants.

Location (city,province)
SYDNEY

3-333-444
COOL JAPAN

SOPHOMORE
Yes

No

NATIVE

Japanese
:

Good

Fair

Poor
Revised on 20/11/2013

Good

Fair

Poor

Good

Fair

Poor

Year or Month
1 YEAR

Revised on 20/11/2013

Period of Involvement
6 YEARS

tional pages as needed.

mple.

year 2000

wed to take part again.

to the best of my knowledge.

ENESYS 2.0

elines for JENESYS 2.0."

ormation

m
ion (ANNEX).

(Day)

(Month)

(Year)

Revised on 20/11/2013

agree to his/her participation.

Day)

(Month)

(Year)

Revised on 20/11/2013

Revised on 20/11/2013

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