Professional Documents
Culture Documents
0 Programme
(Country:
1. Personal Information
Photo
(taken within 3
months)
Please write
your name on
the back of your
photo.
(Day)
Date of Birth
(as shown on your
passport)
(Month)
(Year)
Nationality
Religion
Buddhist
Hindu
(
Christian
Muslim
Roman Catholic
Protestant ) Other
(
Others
Mother Tongue
Marital Status
Number
Passport**
Type of Passport
Date of Issue
(Day)
Private
Date of Expiry
(Month)
(Year)
(Day)
Address
Current Address
Tel:
Fax:
Mobile:
E-mail:
Full Name
Contact Person
in Emergency
*It shall be your parent.
*If you live with him/her, please
leave address blank.
Address
Tel:
Fax:
Mobile:
E-mail:
Profession/Occupation:
Full Name
*If you do not have phone at
your current address, please
write contact person and
number.
Revised on 20/11/2013
Phone Number:
E-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.
Revised on 20/11/2013
2. Health Condition
Blood Type
UNKNOWN
AB
Good
Health Condition
Medicine
Pregnancy
*for women
Yes No
None
Food Allergies
(which may cause allergic Shrimp Crab
reaction)
Others (
Shellfish
Fish
Egg
)
None
Food Restriction
(for religion or custom
reason)
Pork
Beef
Fish
Egg
Chicken
Others (
Shellfish
)
*Please be noted that the meals provided in the programme cannot meet all the requests from the participan
Dietary
Requirements
None
None
Vegitarian
Dogs
Halal
Others (
House dust
Others (
Vegan
Cats
3. Academic Details
Name of School / University
Tel:
Information of your
School/University
Fax:
Profession/Occupation:
Title
English Proficiency
certificated score (if any, e.g. TOEFL)
Level of English
Speaking :
Language
Good
Level of Japanese
Fair
Poor
Speaking :
Good
Fair
Revised on 20/11/2013
Language
Writing
Good
Fair
Poor
Writing
Good
Fair
Reading :
Good
Fair
Poor
Reading :
Good
Fair
Other Language
Japanese learning
experience
Revised on 20/11/2013
4. Personal Activities
Activities
Sports/Clubs
Hobbies
Academic Awards
(if any)
5. Essay
*Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.
6. Other Information
Have you ever been to Japan before?
Yes
No
If Yes, When?
Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.
Participant's Signature:
Date:
(Month)
(Year)
Revised on 20/11/2013
For those who are aged under 18, please have your parent's signiture.
For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.
(Day)
Parent's Signature:
Date:
(Month)
(Year)
Revised on 20/11/2013
ANNEX
Revised on 20/11/2013
Revised on 20/11/2013
Reg.No.
ramme
t) (in English)
Male
Female
Single
Diplomat
(Month)
Married
Official
(Year)
Relationship
Relationship
Revised on 20/11/2013
Revised on 20/11/2013
etc.)
disease etc.)
myasthenia gravis
he programme insurance.
Programme
ab
Shellfish
Location (city,province)
Yes
No
Japanese
:
Good
Fair
Poor
Revised on 20/11/2013
Good
Fair
Poor
Good
Fair
Poor
Year or Month
Revised on 20/11/2013
Period of Involvement
ENESYS 2.0
ormation
m
ion (ANNEX).
(Day)
(Month)
(Year)
Revised on 20/11/2013
Day)
(Month)
(Year)
Revised on 20/11/2013
Revised on 20/11/2013
Revised on 20/11/2013
1. Personal Information
Photo
(taken within 3
months)
Please write
your name on
the back of your
photo.
Name
JAMES
SMITH
(Day)
(Month)
(Year)
01
January
1994
Nationality
Religion
AUSTRALIA
Buddhist
Hindu
Roman Catholic
Protestant ) Other
(
Others
(
Christian
Muslim
ENGLISH
Mother Tongue
Marital Status
Number
Passport**
Type of Passport
L1234567
Date of Issue
Private
Date of Expiry
(Day)
(Month)
(Year)
(Day)
01
April
2014
01
Address
Current Address
Fax: +61-1-234-567
Mobile: +61-7-654-321
E-mail: jenesys2.0@cool.japan
Full Name
PETER SMITH
Contact Person
in Emergency
*It shall be your parent.
*If you live with him/her, please
leave address blank.
Address
123 JENESYS ROAD, SYDNEY, NSW 4567, AUSTRALIA
Tel: +61-1-234-567
Fax: +61-1-234-567
Mobile: +61-7-987-654
E-mail: social_community@cool.japa
Profession/Occupation:
Full Name
*If you do not have phone at
your current address, please
write contact person and
number.
Revised on 20/11/2013
Phone Number:
E-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.
Revised on 20/11/2013
2. Health Condition
Blood Type
Health Condition
UNKNOWN
AB
Good
Medicine
Pregnancy
Not
taking any medicines
Yes No
None
Food Allergies
Shellfish
Fish
Egg
)
None
Food Restriction
(for religion or custom
reason)
Pork
Beef
Fish
Egg
Chicken
Others (
Shellfish
)
*Please be noted that the meals provided in the programme cannot meet all the requests from the participan
Dietary
Requirements
Other Allergies and
Restriction
None
Vegitarian
Halal
Others (
House dust
Others (
Vegan
None
Dogs
Cats
3. Academic Details
Name of School / University
JENESYS2.0 UNIVERSITY
Tel: +61-3-111-222
Information of your
School/University
Fax: +61-3-333-444
COOL JAPAN
SOPHOMORE
Profession/Occupation:
Title
English Proficiency
NATIVE
Level of English
Speaking :
Good
Level of Japanese
Fair
Poor
Speaking :
Good
Fair
Language
Revised on 20/11/2013
Language
Writing
Good
Fair
Poor
Writing
Good
Fair
Reading :
Good
Fair
Poor
Reading :
Good
Fair
Other Language
JAPANESE
Japanese learning
experience
Revised on 20/11/2013
4. Personal Activities
Activities
Sports/Clubs
FOOTBALL
Hobbies
Academic Awards
(if any)
5. Essay
*Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.
6. Other Information
Have you ever been to Japan before?
Yes
No
If Yes, When?
Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.
Participant's Signature:
Date:
(Month)
(Year)
Revised on 20/11/2013
For those who are aged under 18, please have your parent's signiture.
For parents, please sign if you understand all the contexts written on the distributed documents and agree to his/her participation.
(Day)
Parent's Signature:
Date:
(Month)
(Year)
ANNEX
Revised on 20/11/2013
Revised on 20/11/2013
Reg.No.
ramme
t) (in English)
20
Male
Female
Single
Married
Diplomat
Official
(Month)
(Year)
April
2024
-1-234-567
enesys2.0@cool.japan
Relationship
FATHER
-1-234-567
ocial_community@cool.japan
Relationship
Revised on 20/11/2013
Revised on 20/11/2013
etc.)
disease etc.)
myasthenia gravis
he programme insurance.
Programme
ab
Shellfish
Location (city,province)
SYDNEY
3-333-444
COOL JAPAN
SOPHOMORE
Yes
No
NATIVE
Japanese
:
Good
Fair
Poor
Revised on 20/11/2013
Good
Fair
Poor
Good
Fair
Poor
Year or Month
1 YEAR
Revised on 20/11/2013
Period of Involvement
6 YEARS
mple.
year 2000
ENESYS 2.0
ormation
m
ion (ANNEX).
(Day)
(Month)
(Year)
Revised on 20/11/2013
Day)
(Month)
(Year)
Revised on 20/11/2013
Revised on 20/11/2013