NATIONAL BOARD FOR THE PLACEMENT AND PROTECTION

INDONESIAN OVERSEAS WORKERS

Jl. MT. Haryono Kav.52 Jakarta Selatan-17220, Lt.5,
Telp/Fax : 021-7901158

Form 6

Information Sheet of Applicants for Indonesian

Candidate for "Kaigofukushisi"

ID Registration : JBA180300
Name : ANGGA SETIA WIGUNA
Sex : L
Date of birth : 31-01-1997
Age : 21
Address : KP. NANGGERANG RT. 3 RW. 1 KARANGSARI BINONG
SUBANG
Telephone number : 08997810357
Email : anggasw00@gmail.com

Spouse/Dependent children
Number of dependent : 0
children
Mariage Status : Single
Responsible to support your : No
spouse
Family or relatives living in : No
Japan
Relationship : -

Pasport Number :
Date of Expiration : 01-01-1970

Education :
Period Nursing School/University Degree Obtained
02-09-2014 to 02-05-2018 SEKOLAH TINGGI ILMU KESEHATAN CIREBON S.KEP
Experience of working aboard (including Japan) :
Period Country Name of workplace Type of occupation
None None None None

Japanese Language Profiency

Level of Japanese Language Profiency Test conducted by the Japan Foundation or Japan Educational Exchanges
and Services : -
Date of acquisition : 00-00-0000
Number of years of studying Japanese :
Period Japanese Language Institution (School) Country
None None None
Other remarks :-
Request to accepting :-
institution
Preference of the : Local Area
facility
Region : Kyushu-Okinawa
Prefecture :-
Specialization :-
Holidays : SUNDAY

Declaration of authenticity of the abovementioned items __________________________

Endorsement by the Natonal Board of the abovementioned duly authenticated documents

__________________________

Note 1 : This form should be used for Indonesian Candidates for "Kaigofukushisi".
Note 2 : The following certificates/documents should be attached.

● Certificate of academic record and diploma of nursing school/university

● Certificate of employment record if the candidate has working experience
● Document to cerify Japanese language ability, for example, certificates of the Japanese-Language
Preficiency Test (if any)
● Other certificate of qualification

Note 3 : This form should be filled out by all candidates and compiled by National Board