Application for JENESYS Programme

The 2012 Invitation Programme for Future Business Counterparts from New Zealand
* Applications are required by March 2, 2012. * It is expected that the selection and notification will take place by March 30, 2012. * Complete the application form with the necessary information and answers. (typed only)

1. Personal Information
Name Attach your Photograph

For multiple choices, please circle or tick the one which applies to you.

Full Name (Exactly the same as your passport)

Given name Nickname

Family Name

Middle Name (if any)

Place of Birth
(City / Town) (Province) (Country)

E-mail address Date of Birth Nationality Passport

(Day)

(Month) Marital Status

(Year)

Sex

Mal e Age

Fema le

Singl e

Marri ed

Passport Number

(Day)

Date of Issue (Month) Place of Issue

( Year)

Type of Passport Doplom Offic at al Date of Expiry (Day) (Month) Issuing Authority

Privat e (Year)

For those who need to fly to Auckland: Please advise the domestic airport which you intend to depart on May 7th

Address Current Address Tel: Mobile: Full Name Address Tel: Mobile: Profession/Occupation: Fax: E-mail: Relationship

Contact Person in Emergency

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

Fax: E-mail:

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2. Health Condition

Health Condition

Good Having Chronic disease: (asthma, chronic obstructive lung disease etc.) chronic lung disease immunodeficiency state chronic heart disease metabolic disease (Specified (diabetes) infectious ( diseases other s
1."Letter of Consent "(Attached form) and a medical certificate issued by your doctor are required in the orientation. 2. Medical treatment cost related to the chronic disease is not covered by the programme insurance. renal dysfunction obesity ) myasthenia gravis

(T cell immunodeficiency etc.) (congenital heart disease, coronary artery disease etc.)

Pregnancy

Yes

No

Pregnant women cannot participate in JENESYS Programme owing to the below reasons. Maternal and child health Rapid aggravation of influenza A (H1N1)

3. Vocational Details
Information on Name of your Company or Company or Organization Organization: Title: Tel: E-mail:
Location: (city / town)

Fax:

4. Academic Achievement and Working Experience

Information on your Academic Achievement and Working Experience

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5. Past Visits to Japan

Have you ever visited Japan before? Ye s If Yes, How long did you stay in Japan? If Yes, what was the purpose of the visit and where did you visit?
*In principle, any candidates who have participated in JENESYS Programme before are not allowed to take part again.

If yes, when? N o

6. Purpose of Participation
What is your purpose of participating in this programme? How do you intend to make use of this experience?

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7.Others
How did you find this programme? On Japanese Embassy website From exparticipantsJapanese company Heard from employee Other (
(name:

Your 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.

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