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

Entry Form for JENESYS 2.0

Traditional Culture / Heritage / Art ( Batch)

Reg.No.

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

Photo (taken within 3 months)

Full Name (Exactly the same as your passport)

Name

Binti Rimayatul Masfi

Given name (English)

Family Name (English)

Middle Name (if any)(English)

Binti

Masfi

Rimayatul

Full Name (in Mother language)

Nickname (Please specify

the name you would like to be called)

Binti Rimayatul Masfi

Rima

Date of Birth

18/12/1992

Age (as of the day of the flight to Japan)

21

Nationality

INDONESIAN

Sex

MF

Religion

Buddhist Christian (Roman Catholic Protestant Other)

Hindu Muslim Others (

Mother Tongue

INDONESIA LANGUAGE

Marital Status

SingleMarried

Number

Type of Passport

Private Diplomat Official

Passport**

Date of Issue

Date of Expiry

(Day) (Month) (Year)

(Day) (Month) (Year)

Current Address

Address : Jl. Kopral Usman Gang Masjid I/35. Malang

Tel Fax

Mobile : 085755938172 E-mail

Contact Person in Emergency

*It shall be your parent.

*If you live with him/her, please leave address blank.

Full Name : Balya Hidhir

RelationshipMy Brother

Address : Jln. Patimura Rt.001/Rw.003 Dsn. Gambar, Ds. Wonodadi Blitar

Tel Fax

Mobile : 081553348870 E-mail

Profession/Occupation : Student

*If you do not have phone at your current address, please write contact person and

Name

Phone Number

E-mail

Please write your name on the back of your photo.

**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.

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

Blood Type

A B O AB don't-know

Health Condition

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 ( )

Medicine

Not taking any medicines

Taking medicines regularlly (Specified )

Pregnancy

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

fish egg others ( )

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

Other Allergies and

Restriction

none

dogs cats house dust others ( )

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

Information of your

School/Organization

Name of School or Organization

STATE ISLAMIC UNIVERSITY OF MAULANA MALIK IBRAHIM MALANG

Location: (city,province)

MALANG, EAST JAVA

Field of study(for university student only)

CHEMISTRY

Grade/school year (for student)

as of the day of the flight to Japan

3,54

Tel:

Title (for supervisor only)

Fax:

Language

English Proficiency

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

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 Language

Arabic Languange

Japanese learning

experience

Year or Month

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

Activities

Period of

Involvement

Sports/Clubs

CSS MoRA (Community Santri of Scholars of Ministry of Religius Affairs)

2010 until now

Hobbies

Song and Dance

2001-2006

Academic Awards

(if any)

Get the best greade when I was in Islamic Junior High (MTs)

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

Please describe your expectation by participating in this programme.

My hope,

I want to get a lot of knowledge and experiences about the development of Japanese culture and technology , such as the way how Japanese people preserve their culture so that its original characterictics still exist up to now, besides method of Japanese to make sophisticated technology instrument.

Besides that, I hope I can increase and support bonding of brotherly with young of other country.

6. Other Information * Please fill in the form in BLOCK LETTERS in Englis

Have you ever been to Japan before?

Yes No

If Yes, When?

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.

Declaration

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

Signature: Date: / / (Day/Month/Year) Agreement of the Application Guidelines for JENESYS2.0

I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2.0.

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