Reg.No.

Entry Form for JENESYS 2.0

(Japanese Pop Culture
1. Personal Information
Photo (taken within 3 months) Please write your name on the back of your photo.
Name * Please fill in the form in BLOCK LETTERS. Full Name (Exactly the same as your passport) Country English Family Name (English) Middle Name (if any)(English)

Given name (English)

Full Name (in Mother language)

Nickname (Please specify

the name you would like to be called)

Date of Birth Nationality Religion Mother Tongue

Day/Month/Year

Age (as of the day of the flight to Japan) Sex MF

Buddhist Hindu

Christian (Roman Catholic Protestant Other) Muslim Others (

Marital Status Number

SingleMarried
Diplomat (Month) Official (Year)

Type of Passport Private Date of Expiry (Day)

Passport**

Date of Issue (Day) Address

(Month)

(Year)

Current Address Tel Mobile Full Name Contact Person in Emergency

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

Fax E-mail Relationship

Address

Tel Mobile Profession/Occupation Name

Fax E-mail Phone Number E-mail

*If you do not have phone at your current address, please write contact person and number.

**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.

EF ver.2(April 9, 2013)

2.Health Condition
Blood Type A B O AB Good Having Chronic disease: 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 others ( ) Not taking any medicines Taking medicines regularlly (Specified Yes No none pork beef chicken mutton/lamb shrimp crab shellfish ) ) don't-know

Health Condition

Medicine Pregnancy Food Allergies (only for physical reason)

fish egg none

others (

Food Restriction (for religion or custom reason)

pork

beef

chicken

mutton/lamb

shrimp crab shellfish )

fish egg

others (

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

Other Allergies and none Restriction dogs

cats

house dust

others (

3. Academic Details
Name of School or Organization Field of study(for university student only) Grade/school year (for student)
as of the day of the flight to Japan

Location: (city,province)

Information of your School/Organization

Tel: Fax:

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

Level of English
Speaking: Good Language Writing : Good Reading : Good Other Language Fair Fair Fair Poor Poor Poor

Level of Japanese
Speaking: Good Writing : Good Reading : Good Fair Fair Fair Poor Poor Poor

Japanese Year or Month learning experience

4.Category
EF ver.2(April 9, 2013)

Category you want Animation Fashion Entertainment to participate in

5. Personal Activities
Activities Sports/Clubs Hobbies
Period of Involvement

Academic Awards
(if any)

6. Interest in pop culture of Japan

Please describe what you are interested in about pop culture of Japan.

7. Expectations

Please describe your expectation by participating in this programme.

8. Other Information
EF ver.2(April 9, 2013)

Have you ever been to Japan before? If Yes, what was the purpose of the visit and where did you visit?

Yes

No

If Yes, When?

*In principle, any candidates who have participated in JENESYS 2.0 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.

Signature:

Date:

(Day/Month/Year)

Agreement of the Application Guidelines for JENESYS2.0 I hereby agree to the qualifications of health conditions and the use of my personal information for the purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0. I accept the situations where any cost of treatment for any complication due to my pre-existing medical conditions or any illness that I acquire as a result of increased vulnerability of myself will not be covered by medical insurance provided by JICE. Signature: Date: / / (Day/Month/Year)

EF ver.2(April 9, 2013)

Reg.No.

Entry Form for JENESYS 2.0

(Japan
1. Personal Information
Photo (taken within 3 months) Please write your name on the back of your photo.
Name * Please fill in the form in BLOCK LETTERS. Full Name (Exactly the same as your passport) English

TARO YAMADA

Given name (English)

Family Name (English) Middle Name (if any)(English)

TARO
Full Name (in Mother language)

YAMADA

DAVID
Nickname (Please specify
the name you would like to be called)

Date of Birth Nationality Religion Mother Tongue Number

Buddhist Hindu

TARO
Age (as of the day of the flight to Japan) Sex

Day/Month/Year 25/12/1989

18
MF

Japanese
Christian (Roman Catholic Protestant Other) Muslim Others (

Japanese
TG123456

Marital Status

SingleMarried
Diplomat (Month) 3 Official (Year) 2010

Type of Passport Private (Year) 2010 Date of Expiry (Day) 3

Passport**

Date of Issue (Day) 3

(Month) 3

kita shinjyuku 1-2-4, tokyo, Japan 123-0045

Current Address Tel 03-999-9999 Mobile 030-456-9999 Full Name Contact Person in Emergency
*It shall be your parent. *If you live with him/her, please leave address blank.

Fax 03-456-9999

TAICHI YAMADA

E-mail taro@yamada.co.jp Relationship father

Address

minami shinjuku 5-6-7, tokyo, Japan 123-0099

Tel 03-456-7890 Mobile 03-456-7890 Profession/Occupation: Name Fax 03-456-7890 E-mail taichi@yamada.co.jp

Singer
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.

*If you do not have phone at your current address, please write contact person and number.

EF ver.2(April 9, 2013)

2.Health Condition
Blood Type A B O AB Good Having Chronic disease: 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 others ( ) don't-know

Health Condition

Medicine

Not taking any medicines Taking medicines regularlly (Specified Yes No none pork none beef chicken mutton/lamb shrimp crab shellfish ) mutton/lamb shrimp crab shellfish ) fish egg pork others ( chicken )

Pregnancy

Food Allergies (only for physical reason) Food Restriction (for religion or custom reason)

beef

fish egg

others (

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

Other Allergies and none Restriction dogs

cats

house dust

others (

3. Academic Details
Name of School or Organization Location: (city,province)

Shinjuku high school

Information of your School/Organization

Tokyo

Field of study(for university student only) Grade/school year (for student)

as of the day of the flight to Japan

3rd

Tel: 03-567-1111 Fax: 03-567-1112

Title (for supervisor only)

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

TOEFL 250

Level of English
Speaking: Good Language Writing : Good Reading : Good Other Language Fair Fair Fair Poor Poor Poor

Level of Japanese
Speaking: Good Writing : Good Reading : Good Fair Fair Fair Poor Poor Poor

Japanese Year or Month learning experience

EF ver.2(April 9, 2013)

4.Grouping
Group you want to Animation Fashion Entertainment participate in

5. Personal Activities
Activities Sports/Clubs Hobbies
Period of Involvement

ski drawing the cartoon

first prize in English contest

2 years 5 months

Academic Awards
(if any)

6. Expectations

Please describe your expectation by participating in this programme.

7. Expectations

Please describe your expectation by participating in this programme.

EF ver.2(April 9, 2013)

8. Other Information
Have you ever been to Japan before? 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 before are not allowed to take part again.

Yes

No

If Yes, When?

Declaration I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.

Signature:

Date:

24

10

/ 2012

(Day/Month/Year)

Agreement of the Application Guidelines for JENESYS2.0 I hereby agree to the qualifications of health conditions and the use of my personal information for the purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0.

Signature:

Date:

24

10

/ 2012

(Day/Month/Year)

EF ver.2(April 9, 2013)