Region V

D I V I S I O N O f C A M A R I N E S S U R

Freedom Sports Complex, Sail Jose, Pili, Caimu ines Sur

DIVISION MEMORANDUM No. nAb . s. 2017

TO Assistant School Division Superintendent CD) Chief and SGOD Chief Public Schools District Supervisors Heads of Pu >lic Secondary Schools Schools Youi h Formation Coordinators All Others/( oncerned

FROM

SUBJECT:

srs/Cc f t ro w)ivis»n

ARNULFO M. BALANE, CESO V/ School Division Superintendent (

%

CALL FOR APPLICANTS TO THE JAPAN-EAST ASEA NETWORK OF EXCHANGE FOR STUDENTS AND YOUTH (JENESYS) 2017 PROGRAM

Date July 28, 2017

1. The Japanese Government, through the Japan International Cooperation Center (JICE) and the Japanese Embassy in Manila in partnership with the Department o f Education is now opening the application for the Japan East-Asia Network o f Exchange for Students and Youths (JENESYS) 2017.

2. For this year, there are two (2) programs under the JENESYS 2017 program through DepEd namely;

• Japan-ASEAN Rugby Youth Exchange• Japanese Language Communication/ Exchange in Japanese culture

3. The program aim to promote mutual trust and understanding among the peoples o f Japan and the Asia-Pacific region and to build a basis for future friendship and cooperation. It also encourages an understanding and dissemination o f Japan economics, society, history, diverse culture, politics and diplomatic relations.

4. Please refer to the enclosures for the details o f the program.Enclosure 1- Qualifications and Requirements for Students and Teacher

Participants Enclosure 2- Application Procedures Enclosure 3- Timeline o f Activities Enclosure 4- JENESYS 2017 Application Form Enclosure 5- VISA Application Form

5. For inquires and other details, please contact Mr. Joseph C. Cruzana our Project Development Officer at 0930-542-2225 or send email at pdocamsur04@gmail.com.

6. Immediate dissemination and appropriate action o f this memorandum is desired.

One Vision and Mission

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Tanggapan ng Pangalawang Kalihim

Each program shall have different set of qualifications and requirements:

Table 1: Important Requirements and Deadlines

Program Age Requirement Required Participants

by JICE

ApplicationDeadline*

Japan-ASEAN Rugby Youth Exchange

15-18 years old

(strictly bom between April 1, 1999 to March 31, 2002}

6 male students

6 female students

3 supervisors

August 11, 2017

Japanese Language Communication/Exchange iff .l pan<»|u» Cmltwe

15-18 years old 20Mghschool SPFL in Mhftngo : students

2 supervisors

September 8, 2017

*The applicants must submit their JENESYS 2017 appHcaXiun to their respective xtudsion office.

A. Qualifications for the Student ParticipantsS Must meet the age requirement stated abowe.s For those who wish to apply for the Japanese Language

; Cotnmimicatiem/Exchange m Japanese Owhrttre program, they vcm&t -be•. presently majoring in Special Program for Foreign Language (SPFL) inNihongo in a DepEd school.

S Philippine passport holder (valid until April 10, 2018 or later), S Mentally and physically fit to travel

S Must be presently enrolled in high schools Must have strong interest in the theme of program, Rugby Sport/Japanese

; . Language and Japanese Culture» 1 •

S. B»« riwaw l » for the Stwteat ParfciciwaatBS Accomplished JENESYS 2017 Registration Form. Fill out the form with

necessary information and answer tn BLOCK LETTERS.S Passport-sized photo. Staple the passport-sized photo taken within the

last three (3) months on the allocated space on the JENESYS 2017 Entry Form.

Office of the Undersecretary for Administration(Administrative Services, Information and Communications Technology, Disaster Risk Reduction and Management,

Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City

■Room 649, Mabmi Bttfldmg; Mobile: +639260820^2; LwidHne: +6326337203, *6326376207 Email: uscc.admin@deped.gov.ph; Faccbook/Twitter (gdepedtayo

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Tanggapan ng Pangalawang Kalihim

S VISA Application Form. Write complete name in BLOCK LETTERS and then sign using ballpoint pen, other areas on the form must be left blank.

✓ 45mm x 45 mm photo. Staple the 45mm x 45mm photo taken within the last three (3) maathson the .allocated space on the VISA .application form.

S Original Passport (valid until April 10, 2018 or later)V Original and updated (2G17) NSO Birth Certificate. Phetoeopy and/or

Expired NSO Birth Certificate will not be accepted.S Scanned copy of Information 'Page and 'Emergency Contact Page of

PassportS Scanned copy of Official School Registration FormS DSWD Clearance. Fill out the attached DSWD Clearance Form and

submit to the nearest DSWD Field Office; DSWD Field Office may require other documentary requdjrejoiejits (For minor participants only), (fox the requirements, please refer to http://www.dswd.gov.ph/faqs/travel- cleciranc&for^minors/)

Note: Submission of plagiarized documents would mean • automatic disqualification to the program.

C. Qualification for Teacher ParticipantsS A bona fide Filipino citizen, under the age of 4£)S Philippine passport holder (valid until April 10, 2018 or later)•/ Mentally and physically fit to travelS Must have strong interest in the theme of program, Rugby Sport/Japanese

Language and Japanese Culture

B. 'Requirements for Teacher ParticipantsS - Accomplished JENESYS 2017 Registration Form. Fill out the form with

.necessary information and answer in BLOCK LETTERS.S Passport-sized photo. Staple the passport-sized photo taken within the

last three (3) months on the allocated space on the JENESYS 2017 Entry Fsaooa,

S. VISA Application Form. Write complete name in BLOCK LETTERS and .• • then «ign using ba^ok^ pen; other areas-on the form must fee left blank.• / 45mm x 45 mm photo. Staple the 45mm x 45mm photo taken within the

last three (3) months on the allocated space on the VISA application form.■/ Original Passport (valid until April 10, 2018 or later)/ Original and updated (2017) NSO Birth Certificate. Photocopy and/or

Expired NSO Birth Certificate will not be accepted.•/ Scanned copy of Information Page and Emergency Contact Page of

Passport

Office of the Undersecretary for Administration(Adnrinisuathte Siinjictifi, Irifamiatioii.amlCommumcations Technology, HjsasXerMiskJieductian auxJManagement,

Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City

ftoom 5W, Mabihi Building; Mobile: +639260320T62rLandline: ^6326337^03, +6326376207 Email: usec.admin@depcd.gov.ph; Faocbook/Twitter @depcdtayo

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Eajatoaran ng CbukasfponTanggapan ng Pangalawang Kalihim

^ Original NSO-certifled Marriage Certificate. Photocopy of Marriage Certificate will not be accepted (For married participants only.)

• Approved Travel Authority (for the requirements, please refer to DepEd Order No. 43 s. 20J 4) (for xyjsMed applicants oxily)

Note: Submission of plagiarized documents would mean automatic disqualification to the program

The following are automatically disqualified:• Applicants who have already studied/stayed in Japan for over three

months period• Applicants wixo have already participated in J®NES¥S/JGZUNA, SSEAYP,

JICA, Japanese Government (Monbukagakusho: MEXT) Scholarship Program, invitation Program of Japan Foundation (JF), Japan National Tourism Organization (JNTO), or HIDA.

D. Terms and Conditions of the Program

The Japan International Cooperation Center (JICE) shall cover the ff. program- related expenses:

• Round trip economy class ticket from/to the international airport in home country to/from Japan;

• Visa application fee• Overseas travel insurance• Accommodation, transportation, and meals within the program in Japan• Admission fees for scheduled activities in Japan

For the Pre-Departure Orientation and Formation Program, travel expenses within the ' Philippines from their residence (province) to Manila (NAIA) and back shall be charged

against Their locatl funds, MOOE. Board and lodging, and meals for the qualified student and teacher delegates shall be charged against 2017 CO-GAS funds, all subject to the ugual accounting and auditing rules and regulations.

Please note -that no cash allowance is provided to the parfcteipanrts. Participant's shall- pay their personal expenses, including passport fee, and purchasing «$U¥e«k« or personal -goods before -or-during the program.

Office of the Undersecretary for Administration(Administrative Services, Information and Communications Technology, Jjisastfir Misk Jlejtiuetiauaud Management,

Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City

Room 519, Mafami Bttfldmg; Mobile: +63*>26632©762; Landiine: “K3326337203, +0326376207 Email: usee.admirK«dcpod.gov.ph; Face book/Twitter (wdepedtayo

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E. Application Procedures

Step 1:

1.

Ision Level

3.

4.

The Division Office (DO) through the School Governance and Operations Division (3G0DJ shall receive the .application of interested students, avtd teacher participants from the schools.The Project Hevelapmeni Officer 2 You-fch Formation Coordinate) shall be the focal person for the JENESYS 2017 receipt of applications in the division level. The YFC shall also facilitate the creation of -the division level JENESYS 2017 Screening Committee and conduct an evaluation and interview of applicants.The division level JENESYS 2017 Screening Committee shall ensure that .the applicants have met and completed all the documentary requirements needed.The DO shall forward to the Regional Office the shortlisted applicants to the program.

Step 2: Regional Level

1. After receiving the JENESYS 2017 nominations from the division offices, each Regional Office tRO) through the Education Support Services Division (ESSD) must conduct a regional screening and must submit to the Central Office (CO) a total of six (6) nominees for both programs.

Program MaleStudent

FemaleStudent

Supervisor

Rugby Exchange 1 1 1Language and

.Exchange ,1 1 1

TOTAL 2 2 2

2\ The shortlisted applicants should scan the application documents and save• • It into one (1) PDF Ble in at least 300 dpi resolution.

3. The RO must submit to the Central Office the rearmed document requirements in PDF file on or before the application deadline of each program.

. -(Please see Table 1: Important Requirements and Deadlines)

4. Each nominee should forward an advance soft -copy to:blss.vfd@deped. eov.ph with subject heading:

Office of the Undersecretary for Administration(Administrative Services, Information afH C&rrmmnwmitms Technology, Disaster Risk Reduction and Management,

Schools Health, Youth Formation, Baguio Teachers'Camp, Education Facilities/ School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City

Room 519, Mabini Building; Mobile: +639260320762; Landiine: +6326337203, +6326376207 Email: usec.admin@deped.gov.ph; Face book/Twitter @depcdt ayo

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LASTNAME_REGION_SCHOOL_JENESYS2017 (ex. DELA CRUZ_RBGION 1_JUAN G. MACARAEG NHS_JENESYS2017)

5. The shortlisted applicants per region must submit to the CO their original and scanned application documents on or before August 25. 2017 (for Rugby Sports Exchange program} and on or before September 29. 2017 (for Japanese Language Communication/Exchange in Japanese Culture program). Scanned documents must be sent via e-mail at blss.yfd@deped.gov.ph.

Step 3: National Level1. The Central Office through the Youth Formation Division (YFD) will

review the applications and conduct the national screening and interview.

2. The YFD will deliberate and provide the list of official Philippine delegates to the.JENESYS 2017 program.

F. Timeline of Activities

E. 1 For Ruehv Exchange Program

Activity DateApfltUcattea Period AllfOisJt 7-1.0, 2017

Application Deadline August 11, 2017IpvaI August 16-18, 2017

Regional level Screening August 21-23, 2017Subsa&skm of the Regional Office’s

consolidated list of nominees to •Central <Qfik>e

August 25, 2017

National Screening and Interview August 30-September 1, 2017Announcement ofthe fimd Philippine

DelegationSeptember 4, 2017

Pre-Departure Orientation and Formation Program

October 7-9, 2017

• l^ugby Youth Exchange Program In Japan

October 10-17, 2017

Office of the Undersecretary for Administration(Administrative Services, Information and Communications Technology, DisasterRisk Reduction and hlanagenwntf

Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City

Room 3*9, Mabirri Bmkitng; Mobile:*63926©33©?6f; Landlme: *63f6337f03, *6326376207 Email: usee. admin@dcped .gov. ph; Faccbook/Twitter @depedtayo

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B.2 For Japanese Language Communication/Exchange in Japanese Culture Program

Activity PafaiApplication Period September 4-6, 2017

AppHpflflfow rUflrillna September 8, 2017Division level Screening September 18-20, 2017Regional Jewel Screening September 25-27,2017

Submission of the Regional Office's consolidated Hat o f nominees to

Central Office

September 29, 2017

National Screening-and Interview October 4-6, 2017Announcement of the final Philippine

DelegationOctober 10, 2017

Pre-Departure Orientation and Formation Program

November 11-13, 2017

Japanese Language Communication/Exchange in Japanese

Culture in Japan

November 14-21. 2017

For inquiries, all concerned may contact Ms. Jen Pascua of the Youth Formation 'Division at (02) 637-9814, or e-mail at biss.vfdftldeped.gov. ph oriennifer.pascua@deoed.gov.ph with the subject heading: Query: JENESYS 2017.

•. For immediate dissemination and appropriate action.

Attachments:1. J®NES¥S 201T Application Form2. VISA Application Form

Office of the Undersecretary for Administration(AdmniSirjaUmSemms, InforniaUon and Communications Technology, Disast&r Risk Reduction and Management,

Schools Health, Youth Formation, Baguio Teachers' Camp, Education Facilities/School Buildings) Department of Education, Central Office, Meralco Avenue, Pasig City

Room 5W/mat>ini3uMing; Mobile: +630260320762; Landline; +6326337203, +6326376207 Email: usec.admin@deped.gov,ph; Facebook/Twitter@depedtayo

,4 E S Y S 2 0 1 7Entry Form 2017

p*

(fU\

Program Title ( Your Country ( )

* Read amJ confmn Qtmllffcatlons forT’articipants in the Application Guidelines for JENESYS2017 before filling out this Entry Form.* Refer, to the Sample and Fill in All the relevant Columns and Sections. Blank Columns are Not Accepted.

1. Personal Information

Photo (taken within 3

months} Ploase write

your name on thtrback of your

photo.

Name

'

Pu?j Name (Exactly the sambas YourBasspoEt)English

Full Name (in Mother Language) {Nickname (English)_ | (the name you like to be called)

Date of BirthDay/IVkmth/Year

/ / Age

Nationality Sex r m r f

Marital Status r Single r Married r Widowed r Divorced

Religionr Buddhist r Christian

TQUicr - (

P Muslim r Hindu r No Religion

Mother Tongue

Number

Passport If you nave no passport, ieavemis section ^ank.

Type of Passport

r Private r Diplomat P Official

Date of issueOayMonfh/Year

/ /

Date of£\pjryDay/Month/Year

V /Facebook Twitter lnstac?ram others

Social Media User Account(s)

3K Your postings may be used in the program reports or website which will be open to the public.

Current Address / Phone Number

Address :

Terl : Mobile :

£-urail ;

5K Your E-mail will be sent notices or requests from JICE or Japanese gpvernrnent after the progracn.

Contact Person in case of Emergency

#!t should be your parent.

Full Name_

Reljfijttjpja&tiip : r P Father P Other

Address :

Tel :

E-mail :

Mobile

•If you have no phone at your address, wrlto a

contact*phone number.

Contact Phone Number {Holder's Name i Holder's E-mail

Entry Form 2017 Pag* 1

4 Fill in AH the Columns anri&l^tians* BiankCoiumi*s me MotAeoepfed.

Health Cfloditlon

*

r Good (Noilang to Declare Below)

P i Have Been Diagnosed (Serious Disease)

Name of Disease ; ( ) P fully recovered f under treatment

P Having Chronic Disease

r Chronic lung disease (aslhma, chronic obstructive Jung disease etc,)T Immunodeficiency state (T ceil immunodeficiency etc.) r Chronic heart disease (congenital heart disease, coronary artery disease etc.)

P Metabolic disease (diabetes) P renal dysfunction P obesity r myasthenia gravis

P Others ► ( )

Mediciner Not Taking Any#Medici«e

r Taking Medicine Regularly -> Name of Medicine: ( )

| Pregnancy r No P Yes —> Stop the Entry Form and consult with Focal Point or Japanese Embassy

Physical Difficultyr No PYtes <■

— If Yes, What Difficulty ? { )

F ;od Allergies (only for physical

I reason)

r none

r pork r beef r chicken P mutton/lamb P shrimp Pcrab r shelifis

rfish r e g g Pothers ( )

FimdResMcUcMi (for religious or custom reason)

a 'Check items oven If you n are punt vogotarian,

P m mP pork P beef P chicken P mutton/lamb P shrim P crab P shellfis •

P fish P egg Pothers —* ( )

% Meals during the program may not meet all the requests or restrictions.

Other Allergies or

P none

Physical Reason: P dogs P cats P house dust ‘~ other (<• ) Religious/Custom Reason: P dogs P cats P house dust Pother — ( )

1 SiwtomgHiibKr No PYes

•)K Smoking under 20 is prohibited in Japan. This information may be used for homestay arrangement.

* Fill in AH the Columns and Sections. Blank Columns are Not Accepted.3, School /Company /OrganizationfasamEsaaaBB«gafesss==nsfaaBB9aBBs

Are you Student or Workimj Youth ?

r Graduate Student P University / College Student r High School / Vocational / Other School Student

P Working Youth P Working Student

School

Working student needs to fill in this part.

Name of School

Field of Study or Name o f Fa^iiUy / Department

Grade / School Year: j

Job Title (for supervisor):!

Loca|Hon (City or Prqytnco)

Company / *. ‘ Organization

Wotl - gstudenineecte to ;itl in this part.

Name o f Company / Organization jLocrtion (City or Province)

Department / Division (Qff|(:e_...... ........... ............ _ ......

Job Title:

;language

Official English Test (If any) ; r TOEFL (score: ) j r TOEIC (score: )

r IELTS (score: ) j f * Other - ( )(score: )

Level o f English

Speaking :P Good P Far P Poor

Writing :P Good P Fair P Poor

Reading :P Good P Fair P Poor

Level o f Japanese

Speaking ; P Good P Fair P Poor

Writing I Sood r Fair P Poor

Reading : P ^ood P Fair P Poor

Have ycui j d i ^ anything mlated to Japan or SJapanese? | 1 Yes r N°

Ex. Japanese Stuffy, Resarcb, Business, Cullurc I

Japanese lYear(s), / Month(s) Learning I

Experience]

E«tcyt:am i2tt1V P » * « 2

* Fill in All the Columns and Sections. Bianfc Ca3toins are Wot Accepted.Visiting Japan

lj Have you been to Japan before? r Yes i r Np. — ao need to fill in beiow.

If Yes, how long did you stay in Japan?

r More than 3 months

- * Stop the Entry Form and consult with Focal Point o r Japanese Embassy

r 3 months or less

If Yes, did you join any o f the following?

r JENESYS / KI2UNA r SSEAYP f~ JICA T MEXT

t j f r jN T O t h id a

Stop the Entry Form and consult with Focal Point or Japanese fipafaa&sy

r None of the above

5. Personal Activiities VI Sports/Clubs How Many Years ? { year(s))

Hobbies/Favorites_ . .............................................. ................. _ _ ..._ .............. .....................

Prizes/Awards (Sports or Academic,

if any)!-M0wui.?k< i

’ J

6. Expectations

What Do You Expect in IbisProgwwn ?

A(Write Your Wish, Hope

or Desire for the Program in Relation to Your

Specific. Study, Woik or Experience,)

Declaration (P lease sign 1 and 2. If the applicant is under 18, parent or guardian needs to sign 3.)

1. I hereby certify that th£ filling in and statements in this form have been made by m yself and are true and correc t

Signature: : •______________________________ Date: / / (Day/Month/Year)

2. I have read and agree to all the Qualifications for Participants, Terms and Conditions and the Handling o f Personal Information in the '^ftRiilicajUonfiwifeliaes^for JEMESYS2017.

* ' 1 ».

Signature: _____________________:______________ ,Date: / I (Day/Month/Year)

3. (Pg rt>nt/6uardian) (assure everybodyconcemed that the declaration above is true and correct

Signature: ___________________________________ Date: / / (Day/Month/Year)

Entry Form 2017-Page 3

J E N E S Y S 20 i7 Entry Form 2017Program MumJaer ( Composite 1st

Your Country ( Japan )

* Read and confirm Qualifications for Participants In the Application Guidelines for JENESYS2017 b^fore fni(ng out thi« €ntfy Form.* Refer to the SamploandFiilinAll tfwTetevant^oiumns and Sections, Blank Columns are Not Accepted.

1. Personal Information

m* *■» #«V Vk AName

Futf Name (Exactly the same as Your Passport)English ~~

Naomi Christine Yamada

Name (in Mother Language) Nickname (English)(the clause ^qu Jike to be-eated)

Chris

Date o f BirthDay/Month/Year

25/7/1992 Age 25

Nationality

Marital Status

Japanese S bx xmSingle □Married □Widowed □Divorced

Religion□Buddhist QChristian vQMuslim

□Other — (

□Hindu DNo Religion

)Mother Tongue jlapaoese

Number

Passport If you have no passport, ie^ve thtesefiiifln blank.

jfM234serDate o f issue

Day/Month/Year

15/3/2015

Type o f Passport

Private □ Diplomat DOfficial

Date of E m iryDay/Month/Year

15/3/2025

Social Media User Actjourrtfs)

(on a voluntary basis)

Facebook

n^omi.yamada

Twitter Instagram

naomin

others

Your postmgsmay be used in the program report or website which will be open to the public.

Current Address / Phone Number

Address : 2-7-1, Nishi-Shinjuku, Shinjuku-ku, Tokyo* 16^-07i6Japan

Tel : 03-6838-2730 Mobile : 080-1234-5678

E-mail: chris@jice.ezweb.jp

Contact Person in case of Emergency

'It should be your parent.

;Fyll Name

‘ *: Ken Robert Yamada

Relationship : OMotherVQFather DOther (

Address : a^-I.NishUShmjuku.Shmjtiku-ku,Tokyo, 183-0716Japan

Tel : 03-6838-2730 Mobile : 490^.12*3456

E-mail : ken@jice.ezweb.jp

*lf you have no phone at your address, write a

contact phone number.

Contact Phone Number ]Holder!s.Name : Holders €-mall

Entry Form 2017 Pago I

1

s

Health Condition

r-^Tj V '-' N 0 f;

* F iilju A U th e C o lu m n s a « d S e c tio n s .B la n k C o lu m n s a r e W ot A c c e p te d .

Health Conditionu *

0t5ood (Nothing to Declare Below) j

□ 1+teveBtjenDiagnosed(SeriousDisease)

Name of Disease: — Ofully recovered Bjunder tceafcaent Q H a v in g Chronic Disease

— OChronic lung disease (asthma, chronic obstructive lung disease etc.)CHmmunocteft^^ ceil immunodeficiency etc.)□Chronic heart disease (congenital heart disease, coronary artery disease etc.)□MeJabi5licifeease (diabetes) Qfanafdysfunetion Oobesity □ myasthenia gravis □Others — * ( )

IWedtcine €lHot T a k i^ Aoy

□Taking Medicine Regularly -* Name of Medicine: ( )

Pregnancy t?No T3 Yes Stop the Entry Form and consult with Focal Point or Japanese Embassy

fHiysicallM fRculty ;fefNo OYas

If Yes, What Difficulty ? ( )

Food A U a r§ ie «| (only for physical 1 reason}

m m m□pork Qbeef □chicken □mutton/lamb Oshrimp Dcrab □shellfish □fish © egg Pothers — ( )

Food Restriction ^foreelktfetts or custom reason)

*Chfick items even if you are pti’ft vegetarian.

□none'Bpork Qbeef Ochicken tDmutton/lamb Oshrimp □crab □shellfish

□fish Oegg □others -* ( )

♦X*Meals during the program may not meet ail the requests or restrictions.

GtherAltergies or Restrictions

□nonePhysical Reason: Qdogs Scats □ house dust □others — ( )

Religious or Custom ReasoMUdogs Qcats JQhause*dust □others —* ( " ’ )

I Smoking Habit© N o DYes$&Smoking under 20 is prohibited in Japan. This information may be u s^ ffir homes^y arrangement.

* Fill in All the Columns and Sections. Blank C oiiim n^^B ^U ^^cap^d .

1— ™ ------------- -Ata youJ&tudentor

Working Youth ?

□Graduate Student □ University / College Student DHigh School / Vocational /<Dthtsr School Sludent

□Working Youth M3vVorking Student

S ch oo l ,

V OffciagjstMcient neadsio (it! in this pari.

Name o f School

.. JapanMetoatiofiaJJ^

Field o f Study or Name o f Faculty I Department

Accounting■(jifaur/atfnooi '** ..* ' »

... ......... . ...,......— .......... ......... .................................. 2nd>Job Tide (for supervisor):

Location (City or Province)

Tokyo

roar

Company/ Organization .

»*

Working student needs to ’ fill in this part.

Name of Company / Organization

, ? ABC International Co., Ltd.

Department / Division / Officer International Investment Dii

Job Tnie: AssistantlVlanager

Locator (City or Pjxwoace)

Tokyo

vision

Language

Official English Test (If any) WTOEFL (score: 100 ) ^BTOEIC (score: 748 )OIELTS (score: ) DOther ( )(score: )

_________ Level o f Engjish _Speaking : QGood ^^JFair DPoor Writing :<€3Good QFair DPoor feeding r^ S ood OFair DPoor

Level o f Japanese Speaking: □Good \0Fair DPoor Writing : DGood OFair «v3Poor Reading : QGood □Fair M O Poor I

Have you done anything related to Japan i^Japanese? j ™ o

Ek. Japai»cse Study, Rosarch. Business, Culturo \

Japanese iYear(s)/Month(s)^Learning ; s month*Experience i

Entry Form 2017 Page 2

•Partner’s profession/occupation (or that ofpargn]^.if applicantisa,minor):

fiUagim prXtf Eefet6RCein Jdp&f1(Please provide delaBs of the guarantor or the person to be visited in Japan)

Name____________________ Tel.____________________________________________________

Address _____________________________________________________

Date of birth ______________ Sex: Male Q Female Q(Day)/(Morirfijy|Vear)

Relationship to applicant ________________________________________________

Professtanor occupation and position___________________________________________

Nationality and immigration.status______________________________________________

Inviter in JapanjPlease write 'same as above' if the inviting person and the guarantor are the same)

Name ______________________ ____________________________________ Tel.______

Address __________________________________________________________ _

Date o f birth_________________ Sex: Male □ Female Q(Dny}/(Month)/(Ycar)

RelaliaDshlpjtoappHcacvt__________________________________________________

Profession or occupation and position _____________________________

Nationality and immigration status_______________________ ________________ _

# errwte/5pecferl circumstances/if any_________________________________________ _Have you ever:• been convicted of a crime or offence in any country?• been sentenced to imprisonmmJt for I y e a r c o u n t r y ? * *m been deported or removed from Japan or any country for overstaying your visa or violating

any Jaw or regulation?• been convicted and sentenced for a drug offence in any country in violation of law

concerning narcofematfjuana,Qpium, stimulants or-psych tropic substances?**• engaged in prostitution, or in the intermediation or solicitation of a prostitute for other

persons, or in Jdte^OMisiao*afa piace-for prostitution, or any other activity directly connected to prostitution?

• committed*traffickingjn^»^^ici€i^^alded^d#ieriot!ommrtsuch an offence?, ** please tick ‘'Yes" if you have received any sentence, even if the sentence was suspended.

If you answered “Yes" to any of the above questions, please provide relevant details.

1 hereby ik c t e thdtlbe statement given abovetsirue andcorrect! understand that immigration status and period of stay to be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not entitle the bearer to enter Japan upon arrival at port of entry if he qr she isiQund.inadmissibte.-'Thereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the J^aneseembassy/consulate-generalwhen such paymenris necessary.*

Date of application_______________________ Signature of a p p l ic a n t ____________________________________{Oay)/{Month)/CYear} “

* It is not mandatory to complete these items.

Any personal information gathered in this application as well as additional information submitted for the visa application (hereinafter referred to as "Retained P csonal lnformation") will he handW^ppropf iately in accordance with the Act on the Protection of Personal Information Held by Administrative Organs (Act No. 58 o f2003, hereinafter, "the Act"). Retained Personal Information will only be used for the purpose of processing the visa application and to the extent necessary for the pwrposes statedinAfttcleS tjfthe Act.

* * □ NoQ

VesQ NoQ

noQ

VesQ N oQ

V« DY « Q noQ

Visiting Japan 44aveyotrbeen to Japan before?

‘ Fill in AH the Columns and Sections. Blank Columns are Not Accepted.

If Yes, hov long did you stay in Japan?

if Yes, <Mytm jtrmany of the following?

*0Yes J □M o no need to fill in below.

□roowthan 3 months -* Stop the Entry Form and consult with Focal Point or Japanese .Embassy

£2*3 months or less

□JENESYS I KIZUNA □SSEAYP □ JICA OMEXT OJF OJNTO OHIDA

♦ Stop the Entry Form and consult with Focal Point or Japanese Embassy

<€?None of the above

5. Personal ActivitiesI Sports/Clubs Athletic Club How Many Years ? ( 5 year(s))

I H obt^/favorKes Travel, Reading (Harry Potter), Animation (One Piece)

■Prizes/Awards

(Sports or Academic, if a ny )

1st Prize, Tokyo Field Competition, ^ A , High School Female Fast Run 100m -W h e n ? ( 0ctobcr2008 )

6. Fxpftntations

WfcatDe You Expect4 in This Program ?

(Write Your Wish. Hope or Desire fo. vhe Program

in Reladon to Your Specific Study, Work

or Experience.)

r,r , m T . _ ^OOOOOOODDDOOCOOOOOOOOOOOOOOOOOOOooooooooooooooooooooooooooooooooOOOOOOOOOOOOOOOOOOOOOOOOOOODQOOD

Declaration (Please sign 1 and 2. If the applicant is under 18j j>arent or guattlianneedstesigfi 3.)

1. I hereby certify that the'tilling in and statements in this form have been made by myseif and are true and correct.

Signature: jL Date: IS / 8 / 2017 (Pav/Month/Yeart

2. I have read and agree’to all the Qualifications for Participants, Terms and Conditions and the Handling af Persocial infocooatiou in the AppUcakksn Guidelines for JENESYS2017.

Signature: Date: IS / 8 I 2017 (Dav/Month/Year)

3. (Parent/Guardian) I asaure everybocfy conGemed lhatthe dectBfation above is true and correct.

Signature: Date: I I (Dav/Month/Year)

Entry Form 2017 P**e 3

•Official use only

(Paste photo here)

45mm x45mm

or 2inx2in

Surnaraejassbownm passport)___________

Given and middle names (as shown in passport)

Other names (including any other names you are or have been known by)

Date of birth______ ______ Place of birth_____________________________________________________iwlbMH)/| Veai) (City) (State or Province) (Country)

Sex: Male LJ Female 0 Marital status: Single Q Married Q Widowed Q Divorced Q

Nationality or citizenship______________________________________________________________________

-Pocmer and/or other nationalities or citizenships ___________________________ _______________

ID No. issued toyou by your government________________________________________

Passport type: Diplomatic □ Official Q Ordinary Q Other Q

Passport No. ________________________________________________

Place ofresue ________________________________________________ Date of issue_______________fDay)/(Month)/(Vear}

Issuinq authority Date of expiry(bayWMonth)/!Yeari

Purpose of visit to Japan______________________ _______________________________________________

Intended length of stay in Japan_____________________________________________________________

•Date of arrival in Japan________________________ _______ ______________________________ _■*Port of entry into Japan_______________________ Name of-shtp or airline___________________________

Names and addresses of hotels or persons with whom applicant intends to stay

' Name Tel.

Address

Dates and duration of previous stays in Japan_______________________________________

Your current residential address (if you have more than one address, please list them all)

Address ________

Tel. Mobile No.

Current profession or ocoyaation im position_____________________________ __

Name and address of employer

Name Tel.

Address

•Partner's profession/occupation for that of parents, if applicant is a minor):

Guarantor or reference in JapanfPiesse provide details of the guarantor or the person to be visited In Japan)

Name___________________ Tel,

Address

Date of birth_____ _______ Sex: Male □ Female □(Day)/(7th)/{Ve3rjRelationship to applicant_________________ _________ _____________

Profession or occupation and position^

Nationality and immigration status___

In Viter in Jap3n{Please write ‘same as above* If the invitfng person and the guarantor are the same)

Name_________________________ ____________ _____ _______________ Tel.^

Address

Date of birth________ Sex: Male □ Female □{Oayj/(Wonthy/(Year)

Relationship to applicant_______________

Profession or occupation and position____________________________________________

Nationality and Immigration status____________________ ___________ ____________

^Remarks/Special circumstances, if any__________________ ____________________

Have you ever:• been convicted of a crime or offence in any country?

• been sentenced to imprisonment for 1 year or more in any country?**

• been deported or removed from Japan or any country for overstaying your visa or violating any law or regulation?

• been convicted and sentenced for a drug offence in any country in violation of law concerning narcotics* marijuana, opium, stimulants or psychotropic substances?**

• engaged in prostitution* or in the intermediation or solicitation of a prostitute for other persons, or in the provision of a place for prostitution, or any other activity directly connected to prostitution?

• committedtraffkking in persons or incited or aided another to commit such an offence?

** Please tick "Yes* if you have received any sentence, even if the sentence was suspended.

if you answered "Yes” to any of the above questions, please provide relevant details.

YesD N o Q

NoQ

N ° D

YcsQ NoQ

NoQ

V esQ HoQ

1 hereby declare that the statement given above is true and correct. I understand that immigration status and period of stay to be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not entitle the bearer to enter Japan upon arrival at port of entry if he or she is found inadmissible."1 hereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the Japanese embassy/consulate-general, when such payment is necessary.*

Date of application______________________ Signature of applicant ____ _________________________{Oay)/(Month)/{Year}

* It is not mandatory to complete these items.

Any personal information gathered in this application as well as additional information submitted for the visa application (hereinafter referred to as “Retained Personal Information'') will be handled appropriately in accordance with the Act on the Protection of Personal Information Held by Administrative Organs ( Act No. 58 of 2003, hereinafter, "the Act"), Retained Personal Information will only be used for the purpose of processing the visa application and to the extent necessary for the purposes stated in Article 8 of the Act.