4a. entry form for jenesys 2.0

Japan International Cooperation Center EF ver.2(April 9, 2013)

Entry Form for JENESYS 2015Reg.No.

Peace Building commemorating 70 years of the end of World War II

1. Personal Information * Please fill in the form in BLOCK LETTERS in English.

Name

Full Name (Exactly the same as your passport)

BHASKORO ABDILLAH MUTHOHAR

BHASKORO MUTHOHAR ABDILLAH

Full Name (in Mother language)

BHASKORO ABDILLAH MUTHOHAR IBAS

Date of Birth 2/12/1996 19

Nationality INDONESIAN Sex

Religion

Mother Tongue INDONESIAN LANGUANGE Marital Status

Number Type of PassportA 5276614

Date of Issue Date of Expiry (08) (05) (2015) (08) (05) (2018)

Given name (English) Family Name (English) Middle Name (if any)(English)

Nickname (Please specify the name you would like to be called)

Age (as of the day of the flight to

Japan)

　☑M　　□F

□Buddhist □Christian (□Roman Catholic □Protestant □Other) 　□Hindu ☑Muslim □Others (　　　　　　　　　　　）

　　☑Single　　□Married

Passport** ☑ Private □ Diplomat □Official

A16

jice:キリスト教部分に詳細を追加（「その他」を選んで「Roman Catholic と書くのを防止）


Tel : - Fax

Mobile : +628 228 441 2435 E-mail : [email protected]

Tel Fax

Mobile : +628 137 859 1000 E-mail

Profession/Occupation WORKERE-mail

**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.

Current Address

AddressJALAN BANGAU SAKTI NO.8 KEL. SIMPANG BARU, KEC. TAMPAN, KOTA PEKANBARU, RIAU

Contact Person in Emergency

*It shall be your parent.*If you live with him/her,

please leave address blank.

Full NameAHMAD ZAINUDDIN

Relationship :PARENTS

AddressJALAN TUNAS MUDA NO. 46, KEL. BUKIT DATUK KEC. DUMAI SELATAN, KOTA DUMAI, RIAU

*If you do not have phone at your current address,

please write contact person and number.

Name Phone Number


2.Health Condition * Please fill in the form in BLOCK LETTERS in English.

Blood Type

Health Condition

Medicine

Pregnancy

*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

3. Academic Details * Please fill in the form in BLOCK LETTERS in English.

□A 　　□B 　　☑O　　 □AB □don't-know　

☑Good

□Previously diagnosed disease:( )

□Having Chronic disease: □chronic lung disease (asthma, chronic obstructive lung disease etc.)

□immunodeficiency state (T cell immunodeficiency etc.)　 □chronic heart disease (congenital heart disease, coronary artery disease etc.)□metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis□others ( )

☑Not taking any medicines

□Taking medicines regularlly (Specified )

□Yes 　☑No

Food Allergies(only for physical reason)

☑none

□pork □beef □chicken □mutton/lamb □shrimp □crab　 □shellfish

□fish □egg □others ( )

Food Restriction (for religion or custom

reason)

□none

☑pork □beef □chicken □mutton/lamb □shrimp □crab　 □shellfish


Other Allergies and Restriction

☑none

□dogs □cats □house dust □others ( )


Name of School or Organization Location: (city,province)RIAU UNIVERSITY

PEKANBARU, RIAUField of study(for university student only)CHEMICAL ENGINEERING

2Tel: 0761-63272

Title (for supervisor only) Fax:

Language

460

Level of English Level of Japanese

Speaking: Good Fair Poor Speaking: Good Fair Poor

Writing : Good Fair Poor Writing : Good Fair Poor

Reading : Good Fair Poor Reading : Good Fair Poor

Other LanguageYear or Month

Information of your School/Organization

Grade/school year (for student)　as of the day of the flight to Japan

English Proficiency certificated score (if any, e.g. TOEFL)

Japanese learning

experience


4. Personal Activities * Please fill in the form in BLOCK LETTERS in English.

Activities

Sports/Clubs

2014-2015

Hobbies READING BOOK, WRITING, AND COOKING 2014

2014-2015

Period of Involvement

1. STUDENTS ASSOCIATION OF CHEMICAL ENGINEERING OF RIAU UNIVERSITY, SCIENCE FORUM DIVITION

2. DARUL HIJRAH ISLAMIC STUDENT ASSOCIATION, PUBLIC RELATIONS

Academic Awards(if any)

1. THIRD WINNER OF PKM-P HIMATEKI RIAU UNIVERSITY2. FINALIST NATIONAL YOUTH SCI-TECH PAPER COMPETITION


5. Expectations * Please fill in the form in BLOCK LETTERS in English.

6. Other InformationHave you ever been to Japan before? Yes No If Yes, When? -

Educational Trip

Please describe your expectation by

participating in this programme.

JENESYS was created by Prime Minister of Japan, Mr. Abe Shinzo at Second East Asia Summit in 2007. This programme aims to foster awareness of youth people, the next generation, who will have an important role in the

development of East Asia Country.

War and chaos is human nature, planted deep in our memory fragment that sealed in our dna. Even since both of son of adam and eve killed each other for their personal interest.

Thousands even millions war has been declared by humans, that bring nothing except losses, sadness, and tears for everyone who involved in.

Wether humans deserve to lived like that? Lived in greed, wrath, and lust to dominating each other. NO. It is time to break that chains and we as youth people, the next generation, together have a power to stop it. "I know not with what weapons World War III will be fought, but World War IV will be fought with sticks and stones" - Albert

Einstein

I believe this programme will inspired many peoples, especially youths in East Asian Country to keep maintain peace in this world. Not only tell that war is bring nothing except destruction for everyone but also to invites

youth to help each others even they have different skin, different colour, different cultures, and different country to make the world unite as one in peace.

I believe, I have chance to be choosen in this programme because I have a will. A will to make the world as a better place also with this programme I hope I can learn more about japanese culture that always inspired my life

everyday.

* Please fill in the form in BLOCK LETTERS in Englisｈ.

If Yes, what was the purpose of the visit and where did you visit?


Passport Scan

Declaration

*In principle, any candidates who have participated in JENESYS 2.0 before are not allowed to take part again.

EF ver.2(April 9, 2013)

Entry Form for JENESYS 2.0

1. Personal Information * Please fill in the form in BLOCK LETTERS.

Name

Full Name (Exactly the same as your passport)English

TARO YAMADA

TARO YAMADA

Full Name (in Mother language)

Date of Birth

Nationality Japanese

Religion

Mother Tongue Japanese Marital Status

Number Type of PassportTG123456

Date of Issue Date of Expiry

kita shinjyuku 1-2-4, tokyo, Japan 123-0045

Profession/Occupation: Singer

(　　Japan　　　）

Given name (English) Family Name (English)

山田太郎

Day/Month/Year 　　　　25/12/1989

□Buddhist □Christian (□Roman Catholic □Protestant □Other) 　□Hindu □Muslim □Others (　　　　　　　　　　　）

Passport** □ Private □ Diplomat □Official

(Day) (Month) (Year) 3 3 2010


Current Address

Tel 03-999-9999 Fax 03-456-9999

Mobile 030-456-9999 E-mail [email protected]

Contact Person in Emergency

*It shall be your parent.*If you live with him/her,

please leave address blank.

Full Name TAICHI YAMADA

Addressminami shinjuku 5-6-7, tokyo, Japan 123-0099

Tel 03-456-7890 Fax 03-456-7890

Mobile 03-456-7890 E-mail [email protected]

Photo

(taken within 3

months)

Please write

your name on the back of your photo.

A15

jice:キリスト教部分に詳細を追加（「その他」を選んで「Roman Catholic と書くのを防止）


Name Phone Number


*If you do not have phone at your current address,

please write contact person and number.


2.Health Condition

Blood Type

Health Condition

Medicine

Pregnancy


3. Academic DetailsName of School or Organization

Shinjuku high school

Field of study(for university student only)

3rd

Title (for supervisor only)

Language

TOEFL 250

Level of English Level of Japanese

Speaking: Good Fair Poor Speaking: Good Fair Poor

Writing : Good Fair Poor Writing : Good Fair Poor

□A 　　□B 　　□O　　 □AB □don't-know　

□Good

□Having Chronic disease: □chronic lung disease (asthma, chronic obstructive lung disease etc.)

□immunodeficiency state (T cell immunodeficiency etc.)　 □chronic heart disease (congenital heart disease, coronary artery disease etc.)□metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis□others ( )

□Not taking any medicines

□Taking medicines regularlly (Specified )

□Yes 　□No

Food Allergies(only for physical reason)

□none



Food Restriction (for religion or custom

reason)

□none



Other Allergies and Restriction

□none

□dogs □cats □house dust □others ( )

Information of your School/Organization

Grade/school year (for student)　as of the day of the flight to Japan

English Proficiency certificated score (if any, e.g. TOEFL)


Language

Reading : Good Fair Poor Reading : Good Fair Poor

Other LanguageJapanese learning

experience


4. Personal Activities

Activities

Sports/Clubs ski

Hobbies drawing the cartoon

first prize in English contest

5. Expectations

6. Other Information

Have you ever been to Japan before? Yes No If Yes, When?

Academic Awards(if any)

Please describe your expectation by

participating in this programme.

If Yes, what was the purpose of the visit and where did you visit?

*In principle, any candidates who have participated in JENESYS 2.0 before are not allowed to take part again.


DeclarationI hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.

Signature: Date: 24 / 10 / 2012 (Day/Month/Year)

Agreement of the Application Guidelines for JENESYS2.0I hereby agree to the qualifications of health conditions and the use of my personal information for the purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0.

Signature: Date: 24 / 10 / 2012 (Day/Month/Year)


Reg.No.

* Please fill in the form in BLOCK LETTERS.Full Name (Exactly the same as your passport)

TARO YAMADA

DAVID

TARO

18

Sex

Type of Passport

Date of Expiry

kita shinjyuku 1-2-4, tokyo, Japan 123-0045

Singer

Middle Name (if any)(English)

Nickname (Please specify the name you would like to be called)

Age (as of the day of the flight to

Japan)

　□M　　□F

Other) 　

　　□Single　　□Married

Private □ Diplomat □Official


03-456-9999

[email protected] father

03-456-7890

[email protected]


E-mail




Location: (city,province)

Tokyo

TOEFL 250

Level of Japanese

Speaking: Good Fair Poor

Writing : Good Fair Poor

chronic lung disease (asthma, chronic obstructive lung disease etc.)

chronic heart disease (congenital heart disease, coronary artery disease etc.)□myasthenia gravis

)

crab　 □shellfish

others ( )

crab　 □shellfish

( )

others ( )

Tel: 03-567-1111

Fax: 03-567-1112


Reading : Good Fair Poor

Year or Month


Activities

ski 2 years

drawing the cartoon 5 months

first prize in English contest

Period of Involvement


I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.

24 / 10 / 2012 (Day/Month/Year)

I hereby agree to the qualifications of health conditions and the use of my personal information for the purpose of the operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0.

24 / 10 / 2012 (Day/Month/Year)

4a. entry form for jenesys 2.0

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