By the Government of Japan
Please attach
a recent photograph here
Name of Applicant00/b>s Government_____________________________________________________________
Training Course Title
_____________________________________________________________
Name of Applicant (as in Passport)
__________________________________________________________________________________
(Surname or Family Name)
(Other names in full)
o Group Training o Specially Offered Training
o Group Focused Training o Ordinary Individual Course
o Counterpart
o Others (____________________________________)
(Name of Departure Airport to Japan ________________________________)
Address:
Work:
Telephone:
Fax
:
E- Mail :
Date of Birth Sex Date Month Year o Maleo Female
Marital Status: o Single o Married Nationality: Religion: Home
Telephone:
Fax:
E-mail:
Person to notify in case of emergencyName:
Relationship to you:
Address:
Telephone:
E-mail:
Any restrictions on food and behavior
Educational Record (Tertiary Education)
Institution City / Country Period Qualification Obtained Major fields of Study From ToPresent Place of Employment
Name of Organization (o Governmental o Public o Private oInternational oOthers)
Position / Title of present Job Date of present post attained
Month / Year /
Remarks (e.g. class, rank) or others
Training in Foreing Countries Including Japan
Institution Country Period Qualification Obtained & Subject From To Have you attended for a JICA training Course before?o No o Yes Course Title: Year:
Working Record
Present Place of Employment Description of your work including your responsibilities (Detailed information like number of your subordinates, amount of production, etc. Would be useful for training institutes to organize training curriculum) Previous Employment Organization City / Country Period Position / Title Brief description of your work From ToEnglish Proficiency
Excellent Good Fair Poor Daily / Basic conversation o o o o Understanding Lectures o o o o Discussion o o o o Making Presentations o o o o Writing Academic papers o o o o Giving lectures o o o o (If you have any)Certificated Score
(e.g. TOEFL ) Please attach the certification for your score Mother Tongue: Others Languages spoken:Action Plan after the Training / Seminar
How do you expect to apply skills and knowledge obtained from this training course to your work after your return to your home country?Approval of Superior Officer for the above - Mentioned Plan
(Name of Superior
Officer) _______________________________
(Designation
/ Position of Superior Officer) _______________________________
(Signature) _______________________________
(Recommendation
by Superior Officer)
If accept for training, I agree:
not to bring or invite any member of my family, to carry out such instructions and abide by such conditions as may be stipulated by both the nominating government and the Japanese Government in respect of this course of training, to follow the course of study or training, and abide by the rules of the institution or establishment with which I undertake to study or be trained at, to refrain from engaging in political activities or any form of employment for profit or gain, to submit any progress report or evaluation questionnaires which may be prescribed, return to my home country at the end of my course of study or training, and that training program may be canceled immediately, provided any part of my application documents turn out to be false. I also fully understand that if accepted for training it may be subsequently withdrawn if I fail to make adequate progress, or for any other sufficient cause including physical condition is determined by the Government of Japan.Date:___________________________ Signature:_________________________
Medical History and Examination for JICA Training
Important Notice
Before you complete the
Medical History Questionnaire, you are hereby notified that: medical
conditions resulting from an undisclosed pre-existing condition may
not be financially compensated for by JICA and may result in termination
of your training program.
I understand and accept the terms of this notice. Yes _ No____
Nominee Will Check 00es00or 00o00and Explain Yes No Explanation When Condition at Present a. Have you had any significant or serious illness or injury? (If hospitalized, give place & dates.) b. Have you had any operations or advice by a physician to have an operation? (Give place & dates.) c. Do you currently use any drugs for treatment of a medical condition? (Give name & dose.) d. Have you ever been a patient in a mental hospital or sanitarium or treated by a psychiatrist? (Give place & dates.)Nominee will indicate 00es00or 00o00to each item.
Do you now have or have you ever had the conditions listed below?
(Check each item, if yes, enclose the relevant condition with a circle.)
Yes No Condition a.b.
c.
d.
e.
f.
g.
h.
i.
j
Asthma, emphysema, or other lung conditionsTuberculosis or live with anyone who has tuberculosis
High blood pressure, heart disease
Stomach, liver (hepatitis), or gall bladder disease
Kidney or bladder disease, stone or blood in urine
Diabetes (sugar in the urine)
Depression, excess worry, attempted suicide, or other psychological symptoms
Acquired Immune Deficiency Syndrome (AIDS)
Tumor, abnormal growth, cyst, or cancer
Bleeding disorder, blood disease (sickle cell anemia)
I certify that I have
read the above instructions and answered all questions truly and completely
to the best of my knowledge.
Date Signature of Nominee
