Entry Form for JENESYS 2.0

7/23/2019 Entry Form for JENESYS 2.0

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Entry Form for JENESYS 2.

Science and Technology ( 8th B

1. er!onal "nformation * Please fill in the form in BLO

Name

F#ll Name (E$actly the !ame a! yo#r %a

IZZUR ROZABI

"&&' &*B"

F#ll Name (in +other lang#age)

IZZUR ROZABI

,ate of Birth 2/12/1991

Nationality INDONESIAN LANGUANGE

eligion

+other Tong#e INDONESIAN LANGUANGE +arital Stat#!

N#m-er Ty%e of a!

,ate of "!!#e ,ate of E$%i

(28) (01) (2014) (2

Tel / Fa$

+o-ile E/mail

Tel Fa$

ien name (English) Family Name (English)

□Buddhis □!h"isi#n (□R$%#n !#h$li& □'"$s#n □Oh")

□indu☑

*usli% □Oh"s ( ）

a!!%ort

☑ '"i+#

3#rrent *ddre!!

*ddre!!

J*4*N 'NT'N S'**T" 567 T 001 9 0027 *S''*N 7 J

3ontact er!onin Emergency

"t !hall -e yo#r %arent."f yo# lie :ith himher7

%lea!e leae addre!!

F#ll Name*B,'4 3<*+",

*ddre!! J*4*N 'NT'N S'**T" 567 T 001 9 0027 *S''*N 7 J

Photo

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+o-ile E/mail

rofe!!ioncc#%ation ENTEENE'

..'#ss,$" I $u h#+ # +#lid ,#ss,$" ,l#s 3ll in h ,#ss,$" s&i$n I $u d$n5 h#+ # ,#ss,$" ,l#s l#+ h s&i$

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Name hone N#m-er



2.<ealth 3ondition. 'l#s 3ll in h

Blood Ty%e

<ealth 3ondition

+edicine

regnancy

.'l#s 6 n$d h# h %#ls ,"$+idd in h ,"$g"#%% &#nn$ % #ll

6. *cademic ,etail! . 'l#s 3ll in h

Name of School or rgani=ation

B*9"J*Y* 'N">ES"TY

Field of !t#dy(for #nier!ity !t#dent only)

E3N+"3 ,E>E4+ENT

?th

Title (for !#%eri!or only)

4eel of Engli!h

□* □B □*B □donAt/;no:

ood

□Previously diagnosed disease:

( )

□Having Chronic disease:□chronic lung disease (asthma, chronic ostructi!e lung disease etc."

□immunodeficienc# state (T cell immunodeficienc# etc." □chronic heart disease (congenital heart disease, coronar# arter# disease et□metaolic disease (diaetes" □renal d#sfunction □oesit# □m#astheni□others ( "

Not taking any medicines

□

Taking medicines regularlly (S$ecified )

□ Yes No

Food Allergies(only for hysical reason)

☑none

□$or% □eef □chic%en □mutton&lam □shrim$ □cra □she

□fish □egg □others (

Food e!triction(for religion orc#!tom rea!on)

□none

;$or% ☑eef ;chic%en □mutton&lam □shrim$ □cra □

□fish □egg □others ( )

ther *llergie! ande!triction

☑none

□d$gs □&#s □h$us dus □$h"s (

"nformation of yo#rSchoolrgani=ation

rade!chool year (for !t#dent) #s $ h d# $ h <igh $ =#,#n

Engli!h roCciency&"i3&#d s&$" (i #n g OE>L)



4ang#age

S,#7ing G$$d >#i" '$$" S,#7ing G

?"iing G$$d >#i" '$$" ?"iing G

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ther 4ang#age Ja%ane!elearning

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?. er!onal *ctiitie! . 'l#s 3ll in h

*ctiitie!

S%ort!3l#-!

<o--ie! READING BOO ?RIING BOO AND 'UBLI! S'EAIN

1 !n" >$" Isl#%i& E&$n$%is Sudis >#&ul $ E&$n$%i&s #nUni+"si O B"#@i##

2 Sudn Ass$&i#i$n $ E&$n$%i& D+l$,%n >#&ul $ E&$Businss Uni+"si O B"#@i##

LSO RISE E* UB4 *ANA=ER RD UNIAS RI* UB

C DIRE!OR UNIAS RI* UB *ASARAA IL*U?AN DAN ENOLOG INDONESIA LASER

F INDONESIAN *USLI* UNI SUDEN A!ION $ UNIERSI

*cademic *:ard!(i #n)

1 >INALIS '*HG "i%#2 Businss ,l#n &$%,ii$n 2010 l $u" %ind guid $u" u

2 '*HG *#6# L+l O >#&ul Businss >unding G"#ns O*#ndi"i B#n7

4 '*HG *#6# L+l O> Uni+"si4 Ind$nsi#n Sudn En","nu"shi, A@#"d &"# #nd %#7 I

Ind$nsi#n Bussinss E,$ #nd !$%,ii$n (IBE!) 2011C LI A&&$uning D#s 2011

Bs '#," di S&$" Edu&#i$n !#ll >$" '#," Si%,$siu%N#si$n#l,2011)

F ?is%il#7 Di,l$%# Sssi$n II Rgi$n#l Su"#6##8 !"#i+ Businss 'l#n *#n#g%n E+n 2011

9 !",n '#"# 'n&#"i uh#n di =,#ngJ10 N#i$n#l ?"iing !$%,ii$n $n Ind$nsi#H*#"$&&$

11 In"n#i$n#l !$n"n& >#&ul $ E&$n$%i& #nd Busin12 In"n#i$n#l !$n"n& Sh#"i# E&$n$%i&s E+n S$uh E#s

1 >$"u% S## D##HIB >#i" 201214 "#ining RI* I S,i"i $ A&&l"#

1C "#ining '"sn#i$ns O '*1 >in#lis *#"7 #nd Sll !$%,ii$n IS 2012

1F Bs I%,l%n#i$n Businss Din#" #M7i# 2012J18 >in#lis Businss 'l#n !$%,ii$n A*IO*

19 ?RIING BOO *ngi7# *#7n# Di#n#"# G%,# Li"20 '"sn" in h 1s In"n#i$n#l S%in#" $n u#li #nd AK$"d#6l

21 IRSA In"n#i$n#l !$n"n&22 Businss 'l#n !$ns # SOI Asi# 2012 201

2 ?RIING BOO '"&i7#n A,i S#"#h24 Businss >unding G"#ns O*inis"OE&$n$%i&

2C ?RIING BOO !###n &il An#"# Isl#% d#n =,#n



@. E$%ectation! . 'l#s 3ll in h

lea!e de!cri-e yo#re$%ectation -y

%artici%ating in thi!

%rogramme.

I%i# S#%u"#i !ulu" in =#,#n h 3gu" $ # =#,#ns s#%u"#i 3gu"s #" +" #6ul$us h #" +"

# l#d" 6u sill h#+ h s"$ng ,"in&i,l h 3gu"s #" #6l $ gi+ @ih ,un&u#li in $h"s h 3gu"s @" sh +" sh @hn @#" &#%

#" #ll s#%u"#i @#""i$"s in =#,#nDis&i,lin #nd his @illingnss $ "is7 his li @#s # "s$unding i%,#& $n

dis&i,lin $ 6"ing h% in$ h hu%#n his$" is n$ $"g$n ?hi&&i+iliM#i$n is$" $ h S#%u"#i is # +" di-&ul his$" $ 6 $"g$

#l@#s ins,i"ingL#"ning "$% h =#,#ns s#%u"#i is $n $ h $6&i+s $ $ining in h =#,#ns s#%u"#i h# is h gn"#i$n $ $d# ?hn @ l$$7 # =#,

i &#n 6 #s&"#ind h# #ll h "ui $ h ,"+i$R<&ing $n h 3gu"s s#%u"#i in =#,#n h #" # +" highH%indd ,In &$nn&i$n @ih h s$ul in h "#dii$n $ s#%u"#i $ 3nd ,#& $ %i%di#i$n I%,"is$n $u"sl+s siln #nd &#l% h %ind h"$ugh %di#

%ind &l#"i in hin7ing h @ill g # &l#"i in hin7ing &#l%nss iRl#d L#"ning # &l#"i in hin7ing h =#,#ns #" hings h# &#n n

+" "$$d ?"i d$@n h =#,#ns &ulu" su&h #s ,#& $ %ind #nd &h# is "#d 6 h ,$,l $ Ind$nsi# is $n @# $ ,$,ul#"iM

G"#du#ll h "#dii$n $ =#,#ns s#%u"#i @" $"igin#ll us #s # @&"# g"$u,s h# +nu#ll 6&#% # ,"$ssi$n#l g"$u, $ 7nighs li+ ind,ndnl %#7s h% s7 $ #7 #@# h ,$@"s hld 6

#&h $$7 i @illingl h &$%, @ih #&h $h" $ g"#6 h "$n $ d"%in @h$ is h %$s ,$@"ul $"& On #%,l h#,,nd $

*in#%$$ &l#n l#un&hd #n $Knsi+ $ siM ,$@" #i"# #%il In #&D#nn$u"# @hi&h @#s +nu#ll @$n 6 h *in



h# is h lss$n h# i # =#,#ns s#%u"#i #,,lid in Ind$nsi# sh$uld%us 6 i%,l%nd s$% #" sl&d s$ h# h ng#i+ is #6l $#7 lss$ns "$% 6$h =#,#ns &ulu" lss$ns in h 3ld $ h s#%u

s#%u"#i I is ,"$6#6l h# h s#%u"#i @h$ "6lld n$ 6&#us h @#d$@n 6 h &u""n g$+"n%n

In s"## s#%u"#i in =#,#n h high" h dg" $ # s#%u"#i hn h hs#%u"#i s@$"d %$" h#n usu#l h sudid # l$ $ li"#u" ,$" &>$" h% #&&$"ding $ B$ h high" h l+l $ h s#%u"#i h %$"S#%u"#i li%in# h isn& $ s"## #nd ,l$" h s&in& dis&i,li

Sin& h s#%u"#i +i&$"is in F94 AD h "#liMd h i%,$"#n& $ l14F AD

Su" n$ugh h =#,#ns #" +" ,"in&d in h &$un"5s ,"$g"sh s&ini3& &$%%uni @ill #,,"&i# E+n in h =#,#ns &ulu" in ,$,l @h$ h#+ h 7n$@ldg h usd $ &#ll 5snsi5 $" # ,"s$n @

"$% ,"$ss$" li7nd ,$@"ul l"s h# &#n nIn h &ulu" $ h s#%u"#i in =#,#n d"%in#i$n $ ,u",$s in %$+in@#" h 3"s ,$in ,"snd 6 *us#shi in # 6$$7 6 B$ ,l#ind hh g$#l 6$" #nd h %$" di-&ul h $6&i+s s h %$" di-&ul

i h#,,nL#"ning h =#,#ns '$,l g$#l sing is +" i%,$"#n B 7n$@ing

#nd #,,lid in Ind$nsi#n ,$,l &#n 6 # 6"#7h"$ugh $" Ind$nsi#%issi$n $ h ,$,l $ Ind$nsi#n

Dis&i,lin is #ls$ #,,lid 6 h s#%u"#i in =#,#n E+n h du&# %#in#ining %n#l dis&i,lin ,hsi&#l inll&u#l #nd s,i"iu#l h "

h =#,#ns ,$,l # his i% N$ h#"d $" h% $ dis&i,lin Rl#d$" h% =us # lil l# %#7ing h% l +"



?ih h #i% $ 7n$@ing h 6#si& ,"in&i,ls $ h =#,#ns '$,l dis&su6& dis&i,lin ?ih h &ulu" #nd dis&i,lin $ h =#,#ns &ulu"

h#+ in&$",$"#d =#,#ns &ulu" in$ Ind$n

!$u"#g ,i&7 s#%u"#i in d#h @#s # "sul $ hi" ,s&h$l$gi&#l "#iningis $n $ h "#nsii$n $ #n$h" l+l $ isn& E+n sin& h d#sdu&#i$n h# d#h is 6" h#n #ilu" #nd l$ss

Dilign& &$ndu&d 6 h =#,#ns ,$,l "$% gn"#i$n $ gn"#gn"#i$ns h s#%u"#i In his 6$$7 B$ ,l#ins h# %#$" &h#ngsd$ h"$ugh ,"s+"#n& >$" #%,l in us 20 #"s 6@n 18F0H1

%#n#gd $ &h#ng his &$un" #g"i&ulu"H6#sd &$un"is (#g"i&ulu? s us h$@ h ,"s+"#n& $ =#,#ns s$&i is n$ $nl li%idhn $"g$n ,"i$d h"#" $@+" h =#,#ns ,$,l $ l#"n%#d his$" #s %$i+#i$n $" hi" ,#ssi$n # lss$n h# &#n "i,n h

hi" %$"#l*#n@hil in 194C @ 7n$@ h# h S# $ =#,#n #" ,"in&ing si"$shi%# !i #nd N#g#s#7i !i Ds"u&i$n $ s$% ,#"s $ h @$ &i

in =#,#n 6u d$ n$ ds"$ h s,i"i $ is ,$,l ? 7n$@ h# unil%#n#gd $ "6uild his &$un" 6u #ls$ #l%$s #6l &$ngu"d @$"ld @

l#"gs &$n$% in h @$"ld*#n@hil d$Mns $ #"s l#" @hn h S# $ =#,#n ,"in&d #&#usd 6 h% #g#in h &$uld 6uild hi" &$un" 6#&7 :ui&7l ? @

#6l $ "6uild #" h sun#%i hi in 2$@ h =#,#ns S$&i is # @$"ld ,il$ &$%%uniis # his i% ?

&h#," @ @ill " $ dis&uss



S#%u"#i B$ 6$$7 illus"#d h# h #" n$ $,,$sd $ ling ,$$,,$"uni $" $,,$nns $ g#h" s"ngh $,,$"uni #n

S#%u"#i @#" #&i&s @" n+" h s#% n$@ h #&i&s $" n","&$%,#nis in =#,#n @n 6#n7"u, +" ,$@"ul +n i $nl h %is#7

l @$uld sin7 h =#,#ns #nd h" @ill 6 n$ l $$@+" h =#,#ns #&i&s @ih$u +" nding i%,l%ning n"$,ning 6"#n&hs h# s$% &hild"n h#+ # 3n#n&i#l #&&$uning ss%h "suls #" :ui sunning #nd s#ising N$@ s$% $ is su6sidi#"3n#n& h ,#"n &$%,#n h# is ,"in&ing # ,"$l$ngd ding #nd

,$ssi6l his is # #i"l uni:u =#,#ns &S#%u"#i s$%i%s sh$@ u, s$ #g"l 6n d$ing 6#l n% $"&s i

h#nd h h#+ n$ugh #&i&s $ "i&7 his $,,$nn h"$ugh h #i+igil#n& Aiud &#""id 6 s#%u"#i is l#&7#d#isi&#l #iud #nd l#&7 $

"#, h $,,$nn5s s#n&>igu"s $ s#%u"#i in 6#l3ld li7 # %#n @h$ %#d hi%sl in$ #u

l$$7ing # #ll h ,$ssi6iliis h# $&&In his @$"7 B$ s#id h# # s#%u"#i @h$ is $nl #6l $ %#7 hi%sl #s

li7 # s,#""$@ h# inh#6i ns "$$ $ # h$us h" is n$ sh#",nss i@h$l hing h#,,ning in h @$"ld $nl #6l $ "#&h h g#"dns #"$uns#%u"#i @h$ is #6l $ 5"#d h %ind $ $u" $,,$nn5 li7 #n #gl h#

h @#s #6l $ s "$% h high $ h @$"ld h$@ 6#uiN$ $nl h# #,#" "$% h ,l#su" $ #gl h# &$uld < high #nd ss7 #gl < 6ing #6l $ s us h$@ h n%is #nd ," #" @ihin

d$%in# h 6#l3ld #nd +n #6l $ %#7 $u" $S,#7ing "l#d #d+#n&s in =#,#n h =#,#n '$,l h# B$ &$%%n

h ,"$+d $ 6 ,$,l # h $""$n $ d,l$ing #nd "unning h l



5. ther "nformation<ae yo# eer -een to Ja%an -eforeD s N$ "f Ye!7 9hen

Ed#cational

,eclaration

h =#,#ns S$&i h#s # +" s"$ng &h#"#&" in h @$"7 L$$7ing #h# h &h#"#&" $ h =#,#ns S$&i #" h#"d @$"7ing ,$,l

i%,"$+%n +n =#,#n #" g"$@ing "#,idl #" #6$u 20 $ 0 #"s

N#g#s#7i$@ &$uld h &$un" h# h#s 6n $"n #,#" in h s&$nd &i is #6

in&"#s i @ih$u h h#"d @$"7 $ h g$+"n%n #nd ,u6li& #@#"#,,#"nl h"$ugh h h#"d @$"7 $ =#,#ns '$,l g$ h#nd in h#nd 3n

$ "6uild is g$+"n%n his is @h# @ sh$uld %#7 #n #%,Ind$nsi# # %#$"i *usli% &$un" $ d# h#s ,"in&d 0 #"s#6l $ $+"&$% h in"n#l ,"$6l%s $ h n#i$n h" #" sill # l

&"i%in#ls @h$ "$#% his is # +" uni:u &$un" h$s @h$ #" guil&$ninu $ 6 ,u"sud unil h is guil " diK"n "$% =#,#n Isl

Ind$nsi# @h$ #" *usli%s @h$ d$ n$ @#n $ i%,l%n Isl#%i& #& =#,#n @hi&h h#d $nl us 6gun n$ lss %#gniud D#d *#"&h 11 2hug #"h:u#7 @ih # s"ngh $ 89 @hi&h uli%#l &#us # sun#%i

h S#7u"# <$@"s Bu @h# h#,,ndP h "%#in #g"

>$" &#" $" %$$"&&l "id"s h #" sill @#iing in lin $ g ul # # "hi&s h# h h#+ 6uil # l$ng i% !#n $u i%#g

>in#ll his$" h#s ,"$+n h# h =#,#ns #" # "silin n#i$n $@ins#d ,"in h n@ his$"is

? l$$7 # # n@ =#,#ns his$" sin& h s&$nd d$n#d his &i @ #, inii#ll und"si%#d h @$"ld 6u @#s #6l lgnd#" S$n ?#&"#d 6 A7i$ *$"i# is $n ,"$$ h# =#,#n @#s #6l $ "is "$% #d+

@ih &hn$l$g

?ih his +n I h$, $ u"h" ,l$" h &ulu"#l &$ndii$ns h# is#,,lid in Ind$nsi# gn"#ll #nd ,#"i&ul#"l h *usli% '$,l In %

h" h" #" %#n lss$ns h# I $$7 6u s,&i#ll h$s in h 5dudu&#i$n #nd &hn$l$g $@+" h sh$" "i, @#s #6l $ ins,i" %

QS%#ll n$s 6@n Isl#% #nd =#,#nQ #nd h s$$n &$% u, 6$$7 nh$,d h# h "i,H"l#d du&#i$n &ulu" h"i#g #nd =#,#ns #"

h"$ugh # +" d, in"s in % &$un" $ &h"" 6lO his "i, I h$, $ ,"$+id %#n n@ insighs #6$u h &ulu" h"i#,#ssing $ in h +n =nss #6l $ gi+ % h $,,$"uni $ gn"

h"i#g #nd #" in =#,#n

. 'l#s 3ll in h

"f Ye!7 :hat :a! the %#r%o!e of the i!itand :here did yo# i!itD.In ,"in&i,l #n &#ndid#s @h$ h#+ ,#"i&i,#d in =ENESS 20 6$" #" n$ #ll$@d $ #7 ,#" #g#in



eg.No.

tch)

CK LETTERS in English.

!%ort)

IZZUR

2

Se$

%ort

ry

) (01) (2018)

+iddle Name (i #n)(English)

Nic;name ('l#s s,&i

h n#% $u @$uld li7 $ 6 &#lld)

*ge (#s $ h d#

$ h <igh $ =#,#n)

☑* □>

☑Singl □*#""id

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elation!hi% *ENTS

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E/mail

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$"% in BLO! LEERS in English

":uss "$% h ,#"i&i,#ns


4ocation (city7%roince)

*ALANG !I EAS =AA

Tel 06?1@6??

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4eel of Ja%ane!e

c." gra!is

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2010H2014

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2010H2014

eriod of"nolement

d Businss

n$%i&s #nd

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dis&i,lind $6din $ h &$%%#nd

hi" li+s $" hi" l#d"s h#+ %6u h did n$ ,#"i&i,# in i h

h $u&$% in h @#" And n$@ hh is "$$d in h his$" $ @$"ldn #n #g h"#" hi" his$" is

his ,"$g"#% B&#us $ h i%,#& $#n5s highl d+l$,d #nd dis&i,lindus gn"#i$n$,l #nd h#+ # +" d, "#n:uili

nd h ,"" $ s7 ,#& h"$ughi$n @ill ,"$du& # +" d, ,#& $

h #& #nd h li7 #d+#n#gs$ 6 li6"#d "$% # &ulu" h# is#l% h %ind #nd is @"in in # 6$$7h =#,#ns in Ind$nsi#i" h l$ng" h #d @hn h ,"sn& $ h$s @h$ #" #6l $ $h" l#d"s Du $ ,$@" h i%#g $ =#,#ns s$&i >igh $

h s#%u"#i &l#ss ,"$ssi$n#ls hh did # +" #6ul$us s# 6#l in#%$$ &l#n



6 li%in#d h" is # &ulu" h#6 l#"nd >$" Ind$nsi#n &ulu" $"#i is h ,"$ssi$n#l #iud $ hnd %$" ,$sii$ns 6u h @" l

s # du $ &#"" $u s&in& s&in&#llig"#,h ,#ining #nd &"#%i& #"i%,$"#n i is $ sud h s&in&ss 6$nd h @#" 6g#n in 14F AD#"ning s&in& $usid $ h @#" in

h "#,id ,"$g"ss 6&#us $ h$@hs %$d"n i%s "#ll #,,"&i#$ #&:ui"d h il 5,"$ss$"5 L"$ 6 dnid is h %$s i%,$"#n in h &$ndu&# @ sh$uld h#+ %#n#gd $ "#&hl i is $" @#s $ "#&h $u #nd %#7

h &h#"#&"isi&s $ =#,#ns '$,l,$,l '"$+id # &l#" +isi$n #nd

s $ g usd $ h dis&i,lin 6$h insuls $ hi" dis&i,lin #s sn "$%%#" $ i% i% is "#ll +#lu#6l%6#""#ssd



i,lin &#n #ls$ d"%in h #&u#l#s 6"$ugh $ Ind$nsi# indi"&l @i#n s$&i

$ gi+ d#h #nd #ssu% h# d#h h s#%u"#i h %$" $n g #n$ slHs%i$n # "#i ,#ssd d$@n 6 ,"+i$us&&u""d $ h =#,#ns $" @h# h90 h =#,#ns ,$,l @" inii#ll") in$ # s#H6#sd indus"is

$ h his$"is $ hi" #n&s$"s #nd"$% h his$" $ his #n&s$"s #nd h %$i+#i$n @hi&h &#n i%,"$+

+" &"isis n#%l h ds"u&i$n $is @hi&h h#d 6n d+#s#d #"#s

19F0 h =#,#ns ,$,l n$ $nlhi&h is # &$un" h# h#s h s&$nd

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$"% in BLO! LEERS in Englisｈ



Entry Form for JENESYS 2.0

1. er!onal "nformation . 'l#s 3ll in

Name

F#ll Name (E$actly the !ame a! y

EnglishTA

TARO YAMADA

F#ll Name (in +other lang#age)

,ate of Birth

Nationality Japanese

eligion

+other Tong#e Japanese +arital Stat#!

N#m-er Ty%e of a!

TG123456

,ate of "!!#e ,ate of E$%i

kita shinjyuku 1-2-4, tokyo, Japan 123-45

( Ja%an ）

ien name (English) Family Name (English)

田太郎

D#/*$nh/#" 25!12!1"#"

□Buddhis □!h"isi#n (□R$%#n !#h$li& □'"$s#n □Oh")

□indu □*usli% □Oh"s ( ）

a!!%ort

□ '"i+#

(D#) (*$nh) (#")3 3 21

(D#3

3#rrent *ddre!!

Tel 3-"""-"""" Fa$ 3-456-

+o-ile 3-456-"""" E/mail ta$o

3ontact er!onin Emergency

"t !hall -e yo#r %arent."f yo# lie :ith himher7

%lea!e leae addre!!

F#ll Name TA*+* YAMADA

Address&ina&i shinjuku 5-6-, tokyo, Japan 123-""

Tel 3-456-#" Fa$ 3-456-

Photo

(t ken within 3

onth!)

Ple !e

write "o#r

n e on the

$ %k o& "o#r

photo.



rofe!!ioncc#%ation

Name hone N#m-er

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%lea!e :rite contact%er!on and n#m-er.



2.<ealth 3ondition

Blood Ty%e

<ealth 3ondition

+edicine

regnancy

.'l#s 6 n$d h# h %#ls ,"$+idd in h ,"$g"#%% &#nn$ % #l

6. *cademic ,etail!Name of School or rgani=ation

.hinjuku hi/h s)hoo0

Field of !t#dy(for #nier!ity !t#dent only)

3$'

Title (for !#%eri!or only)

T

4eel of Engli!h

□* □B □ □*B □donAt/;no:

□ood

□

Having Chronic disease:□chronic lung disease (asthma, chronic ostructi!e lung disease etc

□immunodeficienc# state (T cell immunodeficienc# etc." □chronic heart disease (congenital heart disease, coronar# arter# di□metaolic disease (diaetes" □renal d#sfunction □oesit# □m#□others ( "

□Not taking any medicines

□

Taking medicines regularlly (S$ecified )

□ Yes □No

Food Allergies(only for hysical reason)

□none

□$or% □eef □chic%en □mutton&lam □shrim$ □cra


Food e!triction(for religion orc#!tom rea!on)

□none

□$or% □eef □chic%en □mutton&lam □shrim$ □cra


ther *llergie! ande!triction

□none

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"nformation of yo#rSchoolrgani=ation

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@. E$%ectation!

5. ther "nformation

<ae yo# eer -een to Ja%an -eforeD s N$ "f Ye!7 9hen

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lea!e de!cri-e yo#re$%ectation -y

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Signat#re ,ate 24 ! 1 ! 212

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Signat#re ,ate 24 ! 1 ! 21



eg.No.

h $"% in BLO! LEERS

#r %a!!%ort)

O YAMADA

DA7*D

TARO

1#

Se$

%ort

ry

+iddle Name (i #n)(English)

Nic;name ('l#s s,&i

h n#% $u @$uld li7 $ 6 &#lld)

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l h ":uss "$% h ,#"i&i,#

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Tokyo

O 25

4eel of Ja%ane!e

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ease etc."asthenia gra!is

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)

Tel 3-56-1111

Fa$ 3-56-1112



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Documents

Entry Form for JENESYS 2.0