OISCA HUMAN RESOURCES DEVELOPMENT TRAINING PROGRAM•OISCA Headquarters: 17-5, Izumi 2-chome, Suginami-ku OISCA Website: www.oisca.org Applicant 10 No.

Tokyo 168-0063 JAPAN E-mail Address:Telephone 81-3-3322-5161 For Training Program Informations:Fax Nos. 81-3-3324-7111 matsuno@oisca.org

For Other Information:sisca@oisca.orQ

Attach recent

Apply Training Course No.: - ,Passport size photo

Personal History FormInstructions:1. Personal History Form (PHF) must be submitted for an application to be valid, indicating the application source and submittedto by post before the deadline. The maximum validity period for a PHF is one (1) year from date of receipt.2. Please follow directions given, type or print your answer to each question clearly, completely, and concisely.3. Applicants should note that if any relevant information is withheld or is given incorrectly. this application is liable to becancelled any time.

1. Family Name (Last name) First Name Middle Name

I I I I I I2. Permanent Address (CityISlate!Countly) Telephone Numbers

I I Home I IOther

3. Contact Address (CitylState/Country)

I I~oo'l

I:~:all3.1 Religion 3.2 Please mention if you have any taboo foods I things

I I I I4. Gender (Please ,() 5. Civil State (Please,()

M F Single Married Other (Please specify)

CCJ I I I I I I6. Date of Birth 7. Place of Birth 8. Nationality

00 MM yyyy

I I I ICCJ I9. Family Members: (Spouse, Children, Parents, Parents-in-Law) Date of Birth

Name (Family Name, First Nama) Nationality Relationship DO MM yyyy

I II II IEEl II I10. If you have a spouse, specify his/her current occupation and name of organiZation .

•11. Name of person to be notified in case of emergency

I I I IComplete Address

Hislher Telephone Number--------------------------"11 j i

I I12. Have you obtained legal/permanent residence status

in any country other than that of your Nationality?

Yes c=J No c=J13. Have you any relative in OISeA Intemational

or other similar intemational organization?

Yes c:::::J No c=JI''Yu' •• ,'" ~"'" ~, -"'" YO' """m .., IOISCA Form No.1 (2017/05)

From To Position/Job Title:

I ID.~ YYYY I ~ yyyy IOthers (e.g. Bonuses, etc.)

Name and Position of Supervisor:

Term: Part-time CJ Full-time CJ I I I IName and Address of Organization: No.andCategoryofEmployeesyouSupervised:

I I IReason for Leaving: II I

Nature of Business: ...:T..:;:e",le:J:p:;.h:.:;o",n.:.e.:..N:.:0c..'~ -,

I I I IDescribe your Work:

rs. "'" "",.. ,.~~, 'ct, '''"d, •••_ •• ,_~, '''0, .~ ,odd~'oo, ,

20. Are you physically able to travel?

Ves No

CJ CJHow frequently?

FrequentlyBy Air? Ves

CJNo

CJOccasionally

I II I21. Have you ever been arrested, indicted or summoned into court as defendant in a criminal proceeding or convicted, fined or imprisoned for the violation of any law

(excluding minor traffic violations)?Yes NO

CJ CJ22. Have you ever been discharged or forced to resign from any position? Yes No

If "Yes', give details: c:::=J c:::=JI I

23. I certify that the statements made by me in answer to the foregoing questions are true, complete and correct to the best of my knowledge and belief. Permission is given toOISCA to make such investigations as are necessary on the information given above. I understand that any misrepresentation or material omission made herein or In anyother document requested by OISCA renders a staff member liable to termination of service or dismissal.

Dare: I I Signature: I IN.S.

Others(e.q. Bonuses,etc.)

Term: Part-time [=:=J Full-time [=:=JNameand Addressof Organization' No,andCategoryofEmployeesyouSUpeMsed:

-1'-- ' 1 II-R-e-a-so-n-f-o-rL-e-a-v-in-g-,-------1Natureof Business: ,...:T.,:8::;:le:!::p::ho::;n,::e:.,:N.,::o::,;,_________ .

1 -----'1 1'---- --'

r ~- If have had more than four' bs, attach additional pa to record them -

oiscx FormNo,3 (2017/05)

16. Have you previously submitted an application for OISCA Scholarship? If "Yes", indicate date. Yesc=J Noc=J DD MM YYYYcr=J I17.• Have you ever been employed by/assigned in OISCA (regular, trainee, contractual or volunteer)?

If "Yes", please provide details in your Employment Record In Item below. Yesc=J Noc=J18. EMPLOYMENT RECORD: (Starting wlth your presentllatest Job, list every job you have had. Use a separate block for each job. Include also service in the anmed forces

and periods during which you were not gainfully employed and must atlached the Employment Certificate. If you need more space, attach additional pages of the same format.For consulting assignments, please indicate equivalent person-months.

From To rP_o;.;s...;it"'lo""n;.;/J..:;o,;:,b_T"'it...;le"': _

A.~ YYYY I ~ YYYY I '~I 1~ ~L- ...J Name and PosItion of Supervisor:

Others (e.g. Bonuses, etc.) 1 I'Tenm: Part-time c=J Full-time CJ 1 1 NumberandCategoryof EmployeesyouSupervised:

Name and Address of Organization: I II INatune of Business: Telephone No.

Reason for Leaving/Wanting to Leave:

I 1 1 1Describe your Work: (Pis, use allotted fields. Donot write in shaded areas or add spaces, Yollmar atta_cha CVCOrltail')irllladditional infOrmation, if necessary.)

To [---------- - IFrom

B. cs=J YYYY I cs=J yyyy IOthers (e.g. Bonuses, etc.)

Tenm: Part-time C:=J Full-time C:=J I JIN"~ •• ""'" •• d O,M"",;OO' I

Nature of BUSiness: ...:T::e:::;le:tp::.:h~o!:.ne~N~o::.. _

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From To

C.~ YYYY I ~ yyyy I

Position/Job Title,

Name and Position of Supervisor:

I INo.andCategoryof EmployeesyouSupervised:

I 1

Reason for Leaving:

I IName and Position of Supervisor:

14. Beginning with your native language, enter aUlanguages you can command. Please indicate your proficiency by marking the appropriate box._ ..... :;, ..•...• ;:,"" . .~--.. -,..-_ ..... _ ..__ ._-_ .._,. .

Good Fair Slight Good Fair Slight Good Fair Slight Good Fair Slight

15. EDUCATION: (Please give full delails)A. Schools or other formal training from age 14 (e.g. High School, technical school or apprenliceship)

Period of AttendanceFrom To Certificates, Awards or

1"--'Mm"ooa'''"'COOj ~ ~ I M," ~,,"_S~, II ",""~~R_ I

B. University or Equivalent (If "Completed". attached the Copy of Diploma or Graduation Certificate)Period of Attendance

From To Certificates, Awards or

I"--'-"OO'C""'CI ~ ~ I ~"C"m.SW" II D~"~~R__ IC. Post-Graduate Studies (If 'Completed", attached the Copy of Diploma or Graduation Certificate)

Period of Attendance

Completed

y~§ ",§Yes No

Yes No

Completed

y~§ ",§Yes No

Yes No

From To Certificates, Awards or

1"_O'ooO"OO'C"''''CI ~ ~ I ~'"a.~oS~, II D""~~R_~ I ~~§::§From To Certificates, Awards or

IN.m.o,".,."oo,c~.. a.·r ~ ~ I M'"C"~'fSW', II_~_R~'''IE. Professional qualifications or specialized training

I I

D. Part-time Study Program (If "Completed", attached the Copy of Diploma or Graduation Certificate)Period of Attendance

OISCA Form No.2 (2017/05)

~::p§leted

Yes

Yes

NO§No

No

JiI ~ 11=Curriculum Vitae

Date prepared (DIMlY) :~1 Na

m ~* 't153IJ M I F~ e Roman Genderalphabet Last Name (Family Name) First & Middle Name (Given Name)

¥~* ~c,~~ Y/NKanjiFamily name Given name

Married

1:.&fJlI3Date of Birth

~{±fflCurrent Address

~ Academic :):!JJF",9 $tx~ . JM;fJi£)Ic~ ~THistory Duration (DIMlY) Name of School, employer, etc

~

-

-

-

JIl'& Employment -~

History

-

-

-:a Positions Position For Year (s) ~OO~~ held Foreign Language (s)

~Ilk Position For Year (s)~~

Previous Yes I No 13*~ ~~

V5 visits to Japanese English

13 Japan

~ From I I iJ~G .:c O){t!! (Other)~ To I I ~C'

.:c O){t!! ~~Other Signature

OlseA Training Program 2018

OISCA Human Resources Development ProgramApplication Form for Desired Training

(Fill by the Trainee only)To Executive Director, Capacity Building Division

OISCA- InternationalDate

I. Dispatch name of organization (Overseas Training center -entire bureau - branch name and the like)

2. Country

3. Name Family name Given name

4. Age Sex Date of birth Day/

Month/

Year/

5. Desired Training -Course number -Subject name

6. Ambition, Motive as from No.5

7. Past experience of desired training

8. The expectations from OISCA HRD Program.

oiscs Training Program 2018

9. Concerning other activities (voluntarily work, sports, hobbies and a like)

10. Plans after completing the program.

Ii. What do you imagine about group life?

12. Concerning other things (Mention Special item and the like)

OlseA Training Program 2018

Last date of submission

2

OIseA Form

MEDICAL CERTIFICATEQ~~ItIT.

Name Date of Birth:&wr ~~j38

Height Blood Pressure~~ em lfll.J.I:Weight Urine Protein m~ Glucose tf Occult Blood ngIfil.1~m kg I}j< ( ) ( ) ( )

Eyesight Left ;5:13 Righi tiB Blood Typem:t.J Bare imtli .IfIllll!W

Rectified ~IEColour Blindness Erythrocyte Sedimentation Rate Ifu.tt (ESR)f5:Ml mmlhourEye Trouble Syphilism~ ·1tiJ~Chest X-Ray 0 - Indirect m')m~~ Liver G.OP. ( ) 0 -Nonnalfl'r;J~BX~ 0 - Direct i«m~~ JfH~fi~ 0 -Abnormal

GP.T. ( ) 0 - Normal0 -Abnormal

r HBs( ) O-NonnaJ HBs( ) D- NormalAntigen D-Abnormal Antibody D-Abnormal

HBe( ) D- Normal HBe( ) 0- Normal

V Antigen D-Abnormal Antibody D-Abnormal

HeV ( ) 0- NormalD-Abnonnal

Tuberculin Test Positive Negative Anamnesis Remarks.y«)v? lJ :/ IiPl;\ ~tt ~~ &t~fiE • t1frc!lUJi

Ear Trouble Internal Examinationlf~ pqfll.RtJPJTJt

Remarks for Training Abroad#iJ;rWf~t:~ \.)LQ)~ ~ffl Jt

[ hereby certify that all information given above is correct ..t!cO)~2it$JJH:: ~ ~ tJ!tJ. t.);: C ~ ID[t;fj L-~ T

Name of Hospital (1M~::g) Date (~~ B)Address Sffir£!t!l)

Certifier (Mtmlt~) Signature (~~)

Trainee Dispatch NoticeDate

Name:Age:Male / Female

This is to certify that for the purpose of training in

__________ , the above parson will be(subject)

dispatched for period of _month from , to(date)

_______ in , Japan.(organization) (prefecture)

His / her current position of employment is to be

o held during the training,

o change to a leave of absence during the training,

And following completion of the training, when returning to his or her homecountry he or she will perform the following duties.

Name of organization facility:

Address:

Occupation after returning to home country:

Name of the Sending Organization

Position and name of parson responsible:

OlseA Training Program 2018 For only use for Trainee

~

Summary of Sending Organization(Overseas oganization·belonged to / other overseas organization taking part in preparation for training)

Name of oganization

Name of Representative

Address

Tel: Fax:

Date of established

Relation to accepting OISCA's related local oganization and officeOganizationInetrnational Cooperation such as

Type of Activities 1. Human Resourse Development for Rural communities2. Greenazation Activities (tree-planting and enviromental education)3. Rural Development Activities (Agriculture etc ..)

Capital Net Salestrnost recent fiscal year) Number of full-time employees

None None None

Main trading Exports: None(transaction)

partner Countries Imports: None

Name of manager Position: I(Parson responsible)

Have any forged or falsified documents or drawings or documents or drawings containingmisrepresentations been use or provided for the purpose of obtaining improper authorization for entry orresidence of a foreigner or of concealing the facts of improper behavior related to the training or technical

internship for a foreigner?

Yes / No

Fill out if the answer to the question above is "Yes"

Timing:

Content:

Date prepared (DIMlY)Name of sending oganization:

Position & name of parson responsible:

OISCA Human Resources Development ProgramApplication Form for Recommendations and Reasons for Nominating the Candidate

To the Secretary General of OISCA InternationalDate

i. Dispatch Organization name.(OISCA Chapter other training centers)

2. Country

3. Applicants name Family name Given name

4. Age Sex Date of birth Day Month Year/ / /

5. Course No. / Desired training subject

6. Give reasons for that (5)

.

7. How will it be beneficial for the Country, Community or Center etc.

-8. Reasons for selecting the candidate

9. Expectations from training candidate & role after completing the training

10. Methodology and criteria of selection

Ii. Specify any other competent feature (if any)

12. Application filled out by

. . . . .·~·Lastdate for submitting the Application: 12August 2017

o/seA Training Program 2018