Reg.No.

Entry Form for JENESYS Programme

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1. Personal Information * Please fill in the form in BLOCK LETTERS.
Full Name (Exactly the same as your passport)
English
Given name (English) Family Name (English)
Full Name (in Mother language)
Date of Birth
Age (as of the
starting day of
the programme)

Religion
Nationality
Mother Tongue SingleMarried
Number Type of Passport
Private Diplomat Official
Date of Issue Date of Expiry
Relationship
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Profession/Occupation
*If you do not have
phone at your current
address, please write
contact person and
number.
Name 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.
Contact Person
in Emergency
*It shall be your parent.
*If you live with him/her,
please leave address
blank.
Full Name
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Address
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Tel 9499 Fax 9499
Mobile 9499 E-mail f=1h1v=m=d=..},
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Current Address
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Tel 99999999 Fax 949999
Mobile 9949999 E-mail f=vv=m=d=..},
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Buddhist Christian (Roman Catholic Protestant Other)
Hindu Muslim Others (
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Passport**
(Day) (Month) ( Year) (Day) (Month) ( Year)
Nickname (Please specify
the name you would like to be called)
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Day/Month/Year //99
Place of Birth
(Province) (Country)
Sex MF
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Name
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Middle Name (if any)(English)
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Photo
(taken within
3 months)
Please write
your name on
the back of
your photo.
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2.Medical History
Blood Type
Good
Not taking any medicines
Taking medicines regularlly (Specified )
Pregnancy Yes No
none
others ( )
none
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none
dogs cats house dust others ( )
3. Professional Career
Location (city,province)
Speaking: Good Fair Poor Speaking: Good Fair Poor
Writing : Good Fair Poor Writing : Good Fair Poor
Reading : Good Fair Poor Reading : Good Fair Poor
Language
English Proficiency
certificated score (if any, e.g. TOEFL)
72()/ 9
Level of English Level of Japanese
Other Languagge
Japanese
learning
experience
Year or Month
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Details of work Fax
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Food Restriction
(for religion or
custom reason)
pork beef chicken mutton/lamb shellfish egg
*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.
Other Allergies
Information of your
Organization
Name of Organization
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Position (Title) Tel
Health Condition
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Medicine
Pregnant women cannot participate in JENESYS Programme
owing to the below reasons.
Maternal and child health
Rapid aggravation of influenza A (H1N1)
Food Allergies
(only for physical
reason)
pork beef chicken mutton/lamb shellfish egg
A B O AB don't-know
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4. Personal Activities
Period of
Involvement
Hobbies
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Speciality
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5. Other Information
Yes No If Yes, When?
If you have something you want to do with
or for host family, please write them.
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 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 -vu
If Yes, what was the purpose of the
visit and where did you visit?
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*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 Held
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