NOT FOR SALE

Please carefully read the Application Guidance before completing this form.
Note:Type or handwrite clearly, and do not exceed the space provided for each
section.

Deadline is
September 25, 2023 !!

(FOR OFFICE USE ONLY: Registration Number )

The 24th Duskin Leadership Training in Japan

A Program for Persons with Disabilities in Asia and the Pacific (2024)

Please answer the following questions,

and attach your photo.

A photo must show your face and entire body. It must have been taken in the past 3
months.
If you are applying by post, please write your full name on the back of the photo.
If you are applying by email, please send your photo as a separate attachment.

1. Name
First (given) name(s) / Middle name / Second (family) name
Answer:

In your native language

Answer:

In English alphabet
Answer:

2. Sex
1 Male
2 Female
3 Unspecified
Answer:

3. Date of Birth
Year/Month/Day
Answer:

Age(as of September 25, 2023)

Answer:

4. Contact details
1 Home
2 Office
3 Other (please specify)
Answer:

Postal address
Answer:

Country
Answer:

Telephone
Answer:

Fax
Answer:

Mobile phone
Answer:

Email
Answer:

5. Type of disability
1 Physical
2 Visual
3 Hearing
4 Intellectual
5 Mental
6 Other (please specify)
Answer:

6. Nationality
Answer:

7. Native language (mother tongue)

Answer:

8. Religion
Answer:

9. Marital status
1 Single
2 Married
Answer:

10. What do you do?

1 I am a student
2 I work
3 Other (please specify)
Answer:
If you are a student, please provide details of your institution

Name of your School/College/Institution

Answer:

Address
Answer:

Your school Year/Grade

Answer:

Your major
Answer:

When do you expect to graduate?

Answer:

If you have employment or any other kinds of work, please provide details below.

Your organization type

1 NGO
2 Public administration/government
3 Private firm/institution
4 Other type of institution
5 Self-employed
6 Family-run business
7 Freelance
8 Other (details)
Answer:

Name of Your Employer (Organization/Company)

Answer:

Address
Answer:

Telephone
Answer:

Fax
Answer:

Website
Answer:

Email
Answer:

Describe specialty of your organization and its main business

Answer:

Your status
1 Paid staff
2 Unpaid staff/Volunteer
3 Intern/Trainee
4 Other (details)
Answer:
Describe your job details including your present title
Answer:

11. Do you belong to any organization of/for persons with disabilities?

1 No, I don�ft belong to any organization.
2 Yes, I belong to the following organization.
Answer:

If your answer yes,Describe your organization infomation

Name of the organization

Answer:

Address
Answer:

Telephone
Answer:

Website
Answer:

Email
Answer:

Its purpose and activities:

Answer:

How are you affiliated with this organization?

1 Staff
2 Member
3 Volunteer
4 Service user
5 Other
Answer:

Describe your involvement

Answer:

12. Education
A. University/ School
Give the name of the institution from which you graduated, your degree/major and
completion date.
Please exclude information that you have already mentioned in Section 10.

Name 1
Answer:
City/Country
Answer:
Attended From (Month/Year)
Answer:
Attended To (Month/Year)
Answer:
Degree, Certificate or Diploma
Answer:

Name 2
Answer:
City/Country
Answer:
Attended From (Month/Year)
Answer:
Attended To (Month/Year)
Answer:
Degree, Certificate or Diploma
Answer:

Name 3
Answer:
City/Country
Answer:
Attended From (Month/Year)
Answer:
Attended To (Month/Year)
Answer:
Degree, Certificate or Diploma
Answer:

Name 4
Answer:
City/Country
Answer:
Attended From (Month/Year)
Answer:
Attended To (Month/Year)
Answer:
Degree, Certificate or Diploma
Answer:

B. Training/Seminar
List training courses and seminars etc. that you have attended and qualifications
that you hold.

Name 1
Answer:
City/Country
Answer:
training period(Month/Year)
Answer:
Certificates obtained
Answer:

Name 2
Answer:
City/Country
Answer:
training period(Month/Year)
Answer:
Certificates obtained
Answer:
Name 3
Answer:
City/Country
Answer:
training period(Month/Year)
Answer:
Certificates obtained
Answer:

Name 4
Answer:
City/Country
Answer:
training period(Month/Year)
Answer:
Certificates obtained
Answer:

13. Work Experience

Please exclude information that you have already mentioned in Section 10.

Name of employer 1
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
Answer:

Name of employer 2
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
Answer:

Name of employer 3
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
Answer:

Name of employer 4
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
Answer:

14. Reason for applying : Why do you want to participate in this training program?
Answer:

15. Your training plan : What do you want to learn in Japan?

Answer:

16. Your future plan : What will you do after training?

Answer:

17. Your disability

What is the name of your disability?

Please describe details about your disability including medical records.
Answer:

Do you require any assistance in your daily life?

1 YES
2 NO
Answer:

If YES, please answer all appropriate below

A. Aids
1 Electric Wheelchair
2 Manual Wheelchair
3 Crutches
4 Guide dog
5 White cane
6 Other (please specify)
Answer:

B. Personal Assistant
1 Full-time
2 Part-time
Answer:

C. What kind of assistance?

1 Mobility
2 Transferring
3 Eating
4 Cooking
5 Cleaning
6 Clothing
7 Toileting
8 Bathing
9 Other (please specify :)
Answer:

D. Give any additional information which would help us to understand your

disability and condition
Answer:

18. Do you have a dietary, medical or any other restriction in your daily life due
to your religion or health condition?
Answer:

19. Describe your personal history.

Answer.

20. What are your hobbies and interests?

Answer:

21. Have you traveled abroad before?

Give details of any travel experience abroad (e.g., study, training and holidays),
including its destination, duration and purpose.
Answer:

22. How did you learn about this program and where did you get this application
form?
Answer:

23. Your language skills

Please answer number that indicates your level on each section.

A. ENGLISH

Speaking
1 None
2 Basic communication
3 Everyday conversation
4 Business level
5 Native level
Answer:

Listening
1 None
2 Basic communication
3 Everyday conversation
4 Business level
5 Native level
Answer:

Reading
1 None
2 Some words
3 Simple sentences
3 Short stories
4 Newspapers
Answer:

Writing
1 None
2 Some words
3 Simple sentences
4 Short essays
5 Business
6 reports
Answer:

B. JAPANESE

Speaking
1 None
2 Greetings
3 Basic communication
4 Everyday conversation
5 Business level
Answer:

Listening
1 None
2 Greetings
3 Basic communication
4 Everyday conversation
5 Business level
Answer:

Reading
1 None
2 Some letters
3 Simple sentences
4 Short stories
5 Newspapers
Answer:

Writing
1 None
2 Some letters
3 Simple sentences
4 Short essays
5 Business reports
Answer:
C. Do you use or understand any of the followings?

Braille
1 Native language(please specify)
2 English (please tell us the Grade)
3 Japanese
4 Other (please specify)
Answer:

Sign language
1 Native language(please specify)
2 ASL
3 International
4 Japanese
5 Other (please specify)
Answer:

Lip-reading
1 Native language(please specify)
2 English
3 Japanese
4 Other(please specify)
Answer:

D. If you have any other communication skills, please describe below :

Answer:

24. Referee information Give the name and contact details of your referee.

Name
Answer:

Relationship to you
Answer:

Address
Answer:

Occupation
Answer:

Email
Answer:

Telephone
Answer:

Mobile phone:
Answer:

25. Surety information Give the name and contact details of your surety.
Name
Answer:

Relationship to you
Answer:

Address
Answer:

Occupation
Answer:

Email
Answer:

Telephone
Answer:

Mobile phone:
Answer:

26. Who completed this application form?

1 I completed this form by myself.
2 I got help (please give details on the person who completed this form on behalf
of you.)
Answer:

If 2, please answer the following questions

Name
Answer:

Relationship to you
Answer:

Reason for assistance:

Answer:

27. Have you applied for this program before?

1 Yes, I applied (What was the year you applied?)
2 No, this is my first time applying.
Answer:

28. Declaration statement by the applicant

�gI hereby certify that all the information stated above is true, correct and
complete.�h

Your signature (type your name)

Date
Answer:

The end of the form.