Republic of the Philippines Department of Education National Capital Region SCHOOLS DIVISION OFFICE QUEZON CITY Nueva Ecija St. ,Bago Bantay, Quezon City www.depedqc.ph
September 19, 2016
MEMORANDUM TO: Assistant Schools Division Superintendents Chiefs, CID and SGOD To the Principals of the following schools: Carlos Albert HS Dr. Josefa Jara Martinez HS Lagro HS Quezon City HS Sauyo HS Sta. Lucia HS
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Attached is a Memorandum from Alain Del B. Pascua, Undersecretary, Office of tAe-Undersecretary for Administ:Fat:ieft(OOt-ed--September 15, 2016, re: Invitation to the Japan East-Asia Network of Exchange for Students and Youths (JENESYS) 2016: Japanese Language Communication and Experience in Japanese Culture, the contents of which are self explanatory for the information and guidance of all concerned. Immediate and wide dissemination of this Memorandum is de ired.
. ESADA, CESO V wi,// ivision Superintendent L
Thez/CID
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Gmail - Call for Participants to the JENESYS 2016
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Gmail
ICT Classified
Call for Participants to the JENESYS 2016 1 message Youth Formation Division To: [email protected]
Mon, Sep 19, 2016 at 1:39 PM
Good day! Please see attached document for the memo on the Invitation to th e Japanese East-Asia Network of Exchange for Students and Youths (JENESYS) 2016: Japanese Language Communication and Experience in Japanese Culture. Please submit to the Central Office the consolidate list of nominees on or before September 21, 2016 (Wednesday). Kindly read carefully the guidelines, slots allotted for your schools/regions, and application procedure . For your guidance and strict compliance. Should you have any questions, please contact Ms. Jen Pascua at (02) 637-9814. Kindly acknowledge receipt of this e-mail.
Respectfully yours, YOUTH FORMATION DIVISION Department of Education Room 307, 3rd Fir. Mabini Bldg., DepEd Complex, Meralco Ave. , Pasig City [email protected] j 633-7232
This communication may contain confidentia l or privileged information, and is intended solely for the individual or entity tn whom it is originally addressed. Any disclosure, copying. dissemination, or any action taken in reliance to it by others, other than the inten ded recipient is strictly p rohibited. The opinions, conclusions, a nd statements expressed in this messag e ere those of the sender and may not necessarily reffecl the views of the Department of Education.
This commun ication mayconl13in confidential or privileged information, and is intended solely for the individual or entity to whom it is originally addressed. Any disclosure, copying, dissemination, or a ny action taken in relia nce to it by others, other than the intended recipient Is striclty prohibited. The opinions, conclusions, and statements expressed in this message are those of the sender and may not necessarily retlectthe views of the Dep artment of Education.
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JENESYS MEMO_NCR.PDF 573K
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ilqarimrnt uf Eihuatiuu DepEd Complex, Meralco Ave., Pasig City Office of the IDidersecretary for Administration MEMORANDUM TO:
ATrENTION:
Dr. PONCIANO S. MENGUITO Regional Director, NCR MAURO C. DE GULAN OIC, Division of Muntinlupa
FREDIE V. AVENDANO OIC,DivisionofPasig
MELITON P. ZURBANO OIC, Division of Valenzuela
SDS HELEN GRACE V. GO Division of Marikina
SDS LOREfA B. TORRECAMPO Division of Las Pinas
DOMINICO C. IDANAN OIC, Division of Makati
SDS EUZABETH E. QUESADA Division of Quezon City
Mr. BENJAMIN D. SAMSON OIC, DivisionofTaguig
Ms. NERISA S. LOSARIA
WILFREDO A. CABRAL
OIC, Division of Manila
FROM:
SUBJECT:
INVITATION TO TIIE JAPAN EAST-ASIA NETWORK OF EXCHANGE FOR STUDENTS AND YOUTHS (JENESYS) 2016: JAPANESE LANGUAGE
COMMUNICATION AND EXPERIENCE IN JAPANESE CULTURE DATE:
September 15, 2016
The Japanese Government, through the Japan International Cooperation Center (JICE) and the Japanese Embassy in Manila in partnership with the Department of Education is implementing ' the Japan East-Asia Network of Exchange for Students and Youths (JENESYS) 2016: Japanese Language Communication and Experience in Japanese Culture. It aims to promote mutu~ frust and understanding among the people of Japan and to promote globeµ understanding of Japanese society, history, diverse culture, politics, and foreign policy. .
The JENESYS 2016 is scheduled on November 1-8, 2016 in Tokyo, Japan. In partnership with the JICE, DepEd will be sending twenty-eight (28) high school students and two (2) teacher supervisors ~ho will represent the Philippines in the program. Page 1 of6 ~
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~· ,tlqublic of tl1t IJh,ilippiaes
il.eparlnttnt of Ehuratbrn DepEd Complex, Meralco Ave., Pasig Gty
•• Please note that for this batch, priority are the high school students who are studying Japanese Language in the specific DepEd schools that offer Special Progr~ for Foreign Language (SPFL) in Nihongo. Please see attached list of schools that offer the said subject under your region/ division.
The regional office is requested to screen and to· submit the riames of shortlisted applicants directly to the Youth Formation Division, Bureau of Leamer Support Services at [email protected] and [email protected] on or before September 21, 2016 (Wednesday), 5:00PM. A pre-departure orientation and training shall be held on October 29-31, 2016 to help prepare the official national delegates. Expenses for the board and lodging of the participants to this activity shall be charged against OSEC funds while the participant's local travel expenses shall be charged to local funds, all subject to the usual accounting and auditing rules and regulations. All Regional Offices are also requested to assist the delegates in facilitating the expenses. A
Qualifications for the Student Participants ./ A bona fide Filipino citizen, single, 15 to 18 years old (on or before November 1, 2016) ./ Must be presently majoring in Special Program for Foreign Language (SPFL) i!t Nihongo at the respective DepEd School (see attached list) ./ Philippine passport holder (valid until March 13, 2017 or later) ./ Mentally and physically fit to travel ~ ./ Must be presently enrolled in high school ./ Must :have strong interest in the theme of this batch, Japanese Language and Japanese Culture
B. Requirements for the Student Participants ./ Accomplished JENESYS 2016 Registration Form. Fill eut the form with necessary information and answer iri BLOCK LE1TERS. ./ Passport-sized photo. Staple the passp0rt-sized phqto taken within. the last three (3) months on the allocat~ space on the JENFSYS 2016 Entry Form. ./ VISA Application Form. Write complete name jn BLOCK LETfERS and then sign using ballpoint pen, other arek; on the form must be left blank . ./ 45mm x 45 mm photo. Staple the 45mm x 45mm photo taken within the last three (3) months on,_ the allocated space on the VISA application form. ./ Original Passport (valid until March 13, 2017 or late11) :./ Original and updated (2016) NSO Birth Certificate. Photocopy and/ or Expired NSO Birth Certificate will not be accepted.. · ./ Scanned copy of Information Page and Emergency Contact Page of Passport ./ Scanned copy of Official School Registration Form
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ilqiartmmt of E~uratiuu DepEd Complex, Meralco Ave., Pasig City DSWD ~earance. Fill out the attached DSWD Oearance Form and submit to the nearest DSWD Field Office; DSWD Field Office may require other documentary requirements (For minor participants only), (for the reqtrirements, please refer to http/jwww.dswd.gov.ph/faqs/travel-dearance-
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fer-minors/)
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Note: Submission of plagiarized documents would mean automatic disqualification to the program. C. Qualification for Teacher Participants ./ A bona fide Filipino citizen, under the age of 40 ./ Philippine passport holder (valid until March 13, 2017 or later) ./ Mentally and physically fit to travel ./ Must have strong interest in the theme of this batch, Japanese Language and Japanese Culture D. Requirements for Teacher Participants ./ Accomplished JENESYS 2016 Registration Form. Fill out the form with necessary information and answer in BLOCK LETTERS. ./ Passport-sized photo. Staple the passport-sized photo taken within the last three {3) months on the allocated space on the JENFSYS 2016 Entry Form. ./ VISA Application Form. Write complete name in BLOCK LE'ITERS and then sign using ballpoint pen; other areas on the form must be left blank. ./ 45mm x 45 mm photo. Staple the 45mm x 45mm photo taken within the last three (3) months on the allocated sp~ce on the VISA application form . ./ Original Passport (valid until March 13, 20170rlater) _ ./ Original and updated (2016) NSO Birth Certificate. Photocopy and/ or Expired NSO Birth · Certificate will not be accepted. ./ Scanned copy of Information Page and Emergency Contact Page of Passport ./ Original NSO-certified Marriage Certificate. Photocopy of Marriage Certificate will not be accepted (For married participants only.) ./ Approved Travel Authority (for the requirements, please refer to DepEd Order No. 43 s. 2014) (for. qualified applicants only}
Note: Submission of plagiarized documents would mean automatic disqualification to the program The following are automatically disqualified: •
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Applicants who have visited Japan through any invitation program organized by the Japanese Government,. ministties or agencies of Japan* before are not allowed to take part again. *e.g., JENESYS, I
E. Expenses: •
Travel Expenses within the Philippines from their residence (province) to Manila (NAIA) and back .shall be charged against their local funds, MOOE. Board and lodging for the qualified
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~lie &If ~e fl1ilippim?s
ileparbmnt of Duadion DepEd Complex, Meralco Ave., Pasig City
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student and teacher delegates shall be charged against OSEC funds, all subject to the usual accounting and auditing rules and regulations. The organizers (JICE) will shoulder the delegates expenses in Japan. which include the round trip international airfare (Manila - Tokyo - Manila), travel tax, terminal fees, board and lodging, and local transportation in Japan.
F. Application Procedures: The ]ICE have specified particular schools where the JENFSYS 2016 participants must be a student of. In lieu of this, the screening and nomination for this batx:h will be conducted directly by the respective schools. Whoever the school will nominate to the regional office will automatically be considered as part of the delegation unless the applicant did not meet any particular requirement stated by the organizers.
The JICE has specified particular schools where the JENFSYS 2016 participants must be a student of. In lieu of this, the screening and nomination for this batch will be conducted directly by the respective schools. Whoever the school will nominate to the Central Office will automatically be considered as part of the delegatien:-tJ.ftless-the applicant did not-meet any- - particular requirement stated by the organizers.
1. The concerned schools from the respective region must nominate their school's delegate. 2. The Regional Office should conduct a regional screening of the student and teacher applicants from the respective schools. . 3. The shortlisted applicants should scan the application documents and save it into one (1) PDF file in at least 300 dpi resolution. f' 4. The concerned Regional Office must submit to the Central Office the scanned document requirements in PDF file saved in CD-ROMS on or before September 21, 2016 {Tuesday) 5. The nominee should forward an advanced soft copy to: [email protected] with subject heading: LASTNAME_REGION_SCHOOLJENE.5YS2016 (ex. DELA CRUZ_REGION 1JUAN G. MACARAEG NHSJENESYS2016 6. The Cen~al Office will review the applicatio]lS and call for an interview with the nominees. 7. Nommees are advisedj to strictly follow the instructions for submissions. . . 8. Lacking requirements/ incomplete documents might cause delay in the processing of the nomination. Please be mindful of the important instructions indicated herewith.
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1lleparlmmt of E~uadion DepEd Complex, Meralco Ave., Pasig City G. Timeline of Adivities: Japan East-Asia Network of Exchange for Students and Youth Q"ENESYS) 2016 Japanese Language Communication and Experience in JapCl;llese Culture
Activitv Scho9l-level Screening and Nomination to the Region of All Concerned Dep'Ed Schools offering SPFL in Nihongo Regional Office Screening of Student and Teacher Particioonts Submission of the Regional Office's consolidated list of nominees to Central Office National Screening and Interview Announcement of the final Philippine Delegation to JENFSYS 2016 Pre-der - trainin£ and orientation Exchange pro2!'am to Japan
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Date September 14-19, 2016
September 20, 2016 September 21, 2016
Seotember 23, 2016 September 29, 2016
October 29-31, 2016 November 1-8, 2016
For inquiries, all concerned may contact Ms. Jen Pascua of the Youth Formation Division at (02) 633-7232, or e-mail at [email protected] or [email protected] with the subject heading: Query: JENESYS 2016. Attached with this memo are the 1.) 2016 }ENFSYS Application Form and 2.) VISA Application Form. For your guidance and immediate compliance.
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1J.ep:mtm.ent nf Eb~tinn DepEd Complex, Meralco Ave., Pasig City G. Timeline of Adivities: Japan East-Asia Network of Exchange for Students and Youth (JENESYS) 2016 Japanese Language Communication and Experience in Jap~ese Culture
Activitv Scho~l-level Screening and Nomination to the Region of All Concerned DepEd Schools offering SPFL in Nihon~o Regional Office Screening of Student and Teacher .. ts Pcu Submission of the Regional Office's consolidated list of nominees to Central Office National Screeninf! and Interview Announcement of the final Philippine Delegation to JENESYS 2016 Pre-d~.-- ~.... trainin£ and orientation Exchanf!e pro.,-am to Japan
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Date September 14-19, 2016
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September 20, 2016 September 21, 2016 I
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Seotember 23, 2016 Septetnber29,2016 October 29-31, 2016 November 1-8, 2016
For inquiries, all concerned may contact Ms. Jen Pascua of the Youth Formation Division at (02) 633-7232, or e-mail at [email protected] or [email protected] with the subject heading: Query: JENESYS 2016. Attached with this memo are the 1.) 2016 JENFSYS Application Form and 2.) VISA Application Form. For your guidance and immediate compliance.
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ilqiartmmt of E~uadiun DepEd Complex, Meralco Ave., Pasig City Attachment: NCR List of Schools
SCHOOL
F. Torres Gen. Ricardo R. Papa Sr. Memorial Hi School Jose Abad Santos High School l.agro High School School Lakandula Makati Science High School - science High School - Manuel A. Roxas.High School Marikina Science High School · · Muntinlupa Science High . School Pasig Gty Sden<;_e High School Pitogo High School
NAME OF PRINCIPAL Mr. Ricardo B. Delos Santos Dr. Prescilla Gonza Dr. Teresita Evan lisCa Dr. Janet Aribon
CONTACT NO.
TOTAL NO. OF NOMINEFS Teacher Participant on
Student Participant per
02-820-7575 715-8457 532-53.57 416-3199
256--3507 Mrs. Nida Dela Cruz
628-0007
Mrs. l.aUia R. Macalinao Dr. Maria Noemi M Moncada Dr. Dante A Feliz.ardo Mr. Samuel Bulan
49S-5579 955-8421 'I39-'lfl.17
10
?i.fs. Maria Eva . Nacion Mr. Fernando B. Orines
1
252-50'J4
896-2686 897-1362 25-6197 562-2414 t
Mr. Alberto D.
647-4262
Villamor Dr. Emelita Bautista
511-9770
Mr. Jay Mathias A.
628-2177
Arellano Ms. Ma Corazon L. Jose Dr. Janet D. Dionio Dr. Divinelinda E. Dela
Cruz Dr. Anita S. Bohol
882-0460 352-3Z39 897-5100 454-4101 454-filffi
Dr. George P. Tizon
828-0140
Mrs. Lucia D. Herrera Mr. Nelson Quinto Ms. Ma. Ou'istina c.
838-1259
417-3811 291-5591
Salon 10
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JENESYS2016 ~R~eg~·~N~o'.:..._ __
Entry Fonn for JENESYS2016(Theme: Japanese Language and Communication and Experience in Japanese Culture) 1st Batch (Country, Philippines )
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1 p ersonaIInf ormaf ton Photo (taken within 3 months) Please write your name on the back of your photo.
Name
~ Please fiUin the form in BLOCK LETTERS in Enalish_ Full Name IExactlV the same as vour oassoortl • English
Middle Name tit anvllEnolish)
Familv Name
Given name (Enalishl
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0
Nickname (Engllsh)(PJease specify
Full Name (In Mother language)
the name you would like lo be called)
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' Date of Birth
Age (as of the day of
Day/Month/Year
the flighl IO Japan)
Religion
OBuddhist OHindu
OChristian (ORoman Catholic DProlestant OOther) OOltlers (
OMuslim
ONot Applicable
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- Number
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-
-
Tvne of Passnort
I
D Private
Date of Issue (Day)
OF
J
Mother Tongue
Passport**
OM
Sex
Nationality
o Diplomat
DOfficial
Date of l=wnjrv (Year)
(Month)
(Day)
(Month)
(Year)
Twitter lnatagram ' others Facebook Social Media User Name(s) •on a voluntary basis * MOFA and JICE might use your postings related to JENESYS through above mentioned SNS in our reoorts and website. that will oossiblv be o~ to the nublic. Address 1 Current Address
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Tel:
I ~
Mobile I Full Name 1 Conta.ct Person In case of Ememency
E-mail
I
Relationship :
I Profenion/Occupation :
"It shaJI be your parent I *If you Uv• with him/her, Tel please leave addreu Mobiles blank.
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I
.
'>
.
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E-mail:
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Profession/Occuoation : "If you do not have a phone Name s
add•-·
Phone Nuf ber : .
E-mail:
·at rour cur19nt pleHe wl1te a "ntact person and number.
-Passport: II you have a valid passport. please fill in the passport section. If you don 1 ~e a passport. please leave the sedioo blanit_
Ja pan Internationa l Cooperat ion Center
EF ver. 1 (June 17, 2016)
2.HeaIth Cond.ti I on
• Please
OGood OPreviously diagnosed serious disease: ( treatment)
Health Conilllltion
Medicine
till in the rorm in BLOCK LETIERS in Enolish.
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: Dfully recovered I Dunder
DHaving Chronic disease: DChronic lung disease (asthma, chronic obstructive lung disease etc.) Olmmunodeficiency state (T cell immunodeficiency etc.) DChronic heart disease (congenital heart disease, coronary artery disease etc.) DMetabolic disease (diabetes) Drenal dysfunction Dobesity D myasthenia gravis } OOthers ( ONot taking any medicine )
OTaking medicine regularly (Sp&ified
Pregnancy
DYes
Food Allergies (only for physical reason}
Dnone
Food Restriction (for religion or custom reason) "Please check the Items
even Ir you•,. pure veg.iarilf\.
Other Allergies
Dpork
DNo
-Obeef
Dfish Oegg
Dchicken
Dmuttonilamb
Dshrimp
Dcrab
Oshelltish
Oothers (
)
Dnone Opork
Dbeef
Dchicken
Dmutton/lamb
Dshrimp Ocrab
Dshellfish
) Ofish Oegg Dothers ( *Please be noted that JICE will arrange all meals during the program based on the above applied infonnation and the meals provided in the program cannot meet all the requests from the participants.
Dnone Ddogs
Deats
D housedust
D others (
)
Deats
Dhouse dust
Dothers (
)
Other ResJrlctio"- Qnone(for religion or custom reason}
.. Odogs DYes
Smoking Habit
. 3. Academ1~
O No
*Smoking is prohibitted by Japanese Law in case you are under the age of 20. *JICE make use of lhis information only for the homeslay arrangement
Deta1.•s10raamzaf ion
*Only for Students Information of your
• Please fill in the
Name of School
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Grade/School year "Plaue fiil out also this part In caae yo11'1'9 worttlng as of the dav of the flioht students.
to Jaoan Title (for supervisor only)
* Only for Adults Name of Organization
·Prea"" fiU out also this part In case you·,. worttlng students.
form in BLOCK LETIERS in English.
Location: (city.province)
Field of Study or Department
School
Information of your Organization
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Tel: Location: (city.province) ·>
Affiliated dept
·Title
Tel:
Japan Jnt ernational Cooper ation Centr.r
EF ver. I Clune 17, 20 16)
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:c:ngusn r-ruuctency certificated score (if any, e.g.
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TnFFI\
Level of Enalish Language
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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
Japanese
Other Language
learning experience
4. Personal Activities
Year or Month
•
• Please fill in the fonn in BLOCK LElTERS in English.
Activities
Period of Involvement
"
Sports/Clubs Hobbles
Academic Awards (if any)
5.E
tations
• Please fill in 1he form in BLOCK LETTERS in
lish.
Please describe your expectation by participating In this program.
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Jar>an International Cooperation Center
EF ver. I (June 17, 2016)
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6 Other Information
• Please fill in lhe fonn in BLOCK LETTERS in Engfish
Have you ever been to Japan before?
If Yes,your visit Is financed by
...
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No
Yes
Others
Japanese Yourself government, Ministries ( and Agencies of Japan
If Yes, when, what was the purpose of IYour visit and where did you visit?
)
·- -- - -
• less than 3 months
lfYes,.how long did you stay In Japan?
more than 3 months
Remarks App ~cants who have visited Japa11tt11 oughan y 111v11auon prograrn ofig anozect b y Japa nese Govern111e11t 0 1 have aht?ac.Jy han rh1, expeoence or studying or staying in Jap;:in mom Uian 3 months are not eligible lo partteopate
1. 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: _ __,__ _..:_l_ _(Day/MonthfYear)
2. Agreement of the Application Guidelines for JENESYS2016. I hereby agree to all the qualifications written in the Application Guidelines for JENESYS2016. Signature:-----------
Date: ______......__ _.(Day/Month/Year)
3. Agreement to handling of personal infonnation. - - - - -- -- ' hereby agree to the matters stipulated in Application Guidelines with regards to the handling of my personal information(Annex1 ). Signature: _ _ _ _ _ _ _ _ _ _ _ Oate:_ _---"----'---'(Day/MonthfYear) 4. Parent/guardian (If applicant is under 18 years of age): Signature:_ _ _ _ _ _ _ _ _ _ __
Date: - - - ' -_ _...___.(Day/Month/Year) t-
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Japan lnternationa l Coopera t i on Center EF ver. !(June 17, 2016)
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VISA APPLICATION FORM TO ENTER JAPAN
(Paste photo here) 45mmx4Smm
•Official use only
or2inx2in
Surname (as shown in passport)_ _ __ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ Given and middle names (as shown in passport)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Other names (including any other names you are or have been known by) Date of birth
~ (o-ay-)/-(M~on=""'ffi~Vt-ve-a.,...r)
O
Sex: Male
Place of birth
--~(=Ci~fy)---~(S...... ta-te_o_r=Pr-ov-mc-e)---~K~ou-n-try~)-----
0
Female
Marital status: Single
0
Married
0
Widowed
0
Divorced
0
Nationality or citizenship - - -- -- - - - - - - - - -- - -- -- - - -- - - - Former and/or other nationalities or citizenships
--- - ------------- --
ID No. issued to you by y..>ur government Passport type: Diplomatic
0
- - -- --------------------
Official
0
Ordinary
0
Other
0
____
Passport No._ _ _ _ _ _ __ _ _ __ _ _ __ _ _ _ _ __ - -
-
Date of issue~,.__.,.
-+'Place of issue
-----';...,.._~--------===------
(Day)/(Month)/ IYearl
Issuing authority____ _ _ _ __ _ __ __ _ _ _ ___ · Date of expiry Purpose of visit to Japan_ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _t _ __
_
_
""(b...-a~ y)~/(M ~on th~ )/~ ( Y-ea~r)
_ _ __ __
Intended length of stay in Japan
--------------------------~
Date of arrival in Japan
----- ----- -------------------- -
Port of entry into Japan_ _ __ __ _ _ __
Name of ship or airline
- - -- - -- - -- -
Names and addresses of hotels or persons with whom applicant intends to stay Tel._ _ _ __ _ _ __
Dates and duration of previous stays in Japan
- -- - -- ------ -- - - - -- - - -
Your current residential address (if you have more than one address, please list. them all)
Tel.
----- ----
Mobile No.
- -- - - - ---
Current profession or occupation and position Name and address of employer
------ - -------------- -
Address-~~~~~~~~~~~~~-~~~~~~~-~~~-~-
•• .. *Partner's profession/occupation (or that of parents, if applicant is a minor): Guarantor or reference in Japan(Please provide details of the guarantor or the person to be visited In Japan)
Address
----- -- - ------- ---------- -------- -
0a i e of birth
Sex: Male
-,o-a-y~)/(-MO-nth~ )/(Y-ea _r_)
0
D
Female
Re lationship to applicant
- - --------'---'----------------------
Profession or occupation and position
--~-'--------------------
Nation a Iity and immigration status
---------------------- --
Inviter in Japan{Please write 'same as above' if the inviting person and the guarantor are the same)
Tel._ _ __ _ _ _ __
Address
-------------------------- -----------
0 ate of birth_ _ _-,.._ __,_
Sex: Male
_______
(Oay)f{Month)/(Year) Relationship to applicant
0
0
Female
____________________
___.;.._....;.._
Profession or occupation and position
-----:-----------------------
NationaIity and immigration status_ _ _ _,__ ;.__ _ ________________
"Remarks/Special circumstances, if any_--"------'-- """'-'--- -- - - - - - - - - -- -- - Have you ever: e been convicted of a cr\me or offence in any cou11untryU¥1.:--_ _ __ __ _ - -YesQ -NoEl- -
e e e
been sentenced to imprisonment for 1 year or more in any country?*"' been deported or removed from Japan or any country for overstaying your visa or violating any law or regulation? been convicted and sentenced for a drug offence in any country in violation of law . · concerning narcotics. marijuana, opium, stimulants or p5ychotropic substances?""
e engaged in prostitution, or in the intermediation or solicitation of a prostitute for other persons, or In the provision of a place for prostitution, o r any other activity diredly connected to prostitution? e committed trafficking in persons or incited or aided another to commit such an offence?
YesO
No0
YesO
No0
YesO
NoQ
YesO NoO YesO NoO
.. Please·tick "Yes· if you have received any sentence, even if the sentence was suspended.
If you answered "Yes· to any of the above questions, please provide relevant details.
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·1 ~reby declare that the statement given above is true and correct. I understand that immigration status and period of stay to be granted are decided ~the Japanese Immigration authorities upon my arrival. I understand that possession of a visa does not entitle the bearer to enter Japan upon arrival at port of entry if he or she Is found inadmissible." ·1 hereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa Tee to·the Japanese embassy/consulat~eneral, when such payment is necessary.•
Date of application_ _,_~__,_--,-,..,,,.,.~-10ayJ!(Monthl/(Yearl
Signature of applicant ~---------------
• 11 is not mandatory to complete these items.
Any personal information gathered in this application as well as additional information submitted for the visa application (hereinafter referred to as "Retained PersollCll lnformation") will be handled appropriately in accordance with the Act on the Protection of Personal lnfor,:nation Held by Administrative Organs (Act No. 58 of 2003, hereinafter. "the Acr-}. Retained Personal Information will only be used for the purpose of processing the visa application and to the extent necessary fot the purposes · stated in Article 8 of the Act.
