SO Y TE

11. JUL. 2014 10:13
844 846195
SO Y TE
S6 45/0 /BYT-QT.
NO. 127
P
1
CONG 1101 XA HOT CHU NGHQ VIT NAM
Dy do - 1-1hphtic
Eli)c
Ha NOi, ngay thang 7
V/v Chtrung truce JENESY2.0
Kith
................
chuang trinh giao luu TENESY danh cho sixth vien y khoa
Lien quan
ah'4n dugc danh sach
Y , da
Viet Nana sang Nhjt Ban.,
cluang
va
cac sinh vien do q4 Intorng d&' cir than gia chuong trinh. fe hoan tat cac thu
t-kic tiap theo, BO Y to •:1" nghi cac truCmg c6 sinh vien than). fir:
- Cung cap cac thong tin lien quan cua sink vien duge cir tham dui
chuong trinh theo mau girl kem theo.
Thong bao cho sinh vien lam h0 chi'L ph6 thong va hoan thien cac
form dang k57 sau: Form Bong )'7tham gia chuong trinh, Form clang 147
tham gia chuong trinh JENESYS 2M, Form cap visa vao Nhat Ban
sinh vien tavc tiep
(cac form ducic dan anh va day du cb.fi 147).
lien he vox VIA Hop tac Qu6c to de clugc huang dan khai form va nh4n
ban znem qua email. Cac form clang 1(- 7 va ban. gOc ho chiau nOp v" Vu
Hop tie Qu6c to fru-6T ngay 5/8/2014_
theri gian: Ban to chic c6 thong bao th&i gian di Nhat Ban có su
thay cox nhu sau: tir ngay 21-29/10/2014.
Kirsh phi: Ban to chik dai tho town bc) kinh phi, ye may bay, an 6., di
14i cho sinh vien tai Nhat Ban. Caz kinh phi khac truac chuye'n di nhu
h'() chik!, an 6-, di Zai to dza phuong d6n sari bay qu6c t" NOi Bai/Tan
Son Nhat do ca nhan to tic hoc Tr Ong tit sinh vien tham du 113 lay.
Bo Y to tran trong thong bao de qu)'T Tnreng bi6t va, thong bao den cac
sinh vien hoan tat cac dui we cho chuy6n
TL.BQ TRVONG
tzhCin:
KT. VU TRUION....1(U
, HOP TAC QUOC TE
- Nhis trent
IfoNG
n-X130- .
- TT. Le Quang Ctrang (ei" b/c);
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aith Cirefng
"'442ZrakA
Moi thOng tin chi tit lien 1* Ms. WI Ha Thu (DD:0912020382, email: hatlFax
-
6,243,2233.
alloo.com )
11. JUL. 2014 10:13
NO. 127
844 846195
P
Dania sach oh kern then tong van s6z-K.20/BYT-QT ngay 11/7/2014
Fax
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1. True-rig Dai hoc Y Ha NOi
2. Trithng Y Ducic Tp HCM
08 385 523 093. Trueng Dai hoc Y Dirge Thai Nguyen 0.2 Vo 3855740
4. Throng Dai hoc Y Dtreic Thai Binh : 03e 50(1-7509
5. TruCmg Dai hoc Y Dirot Hai Thong : 03A 3-T34,22y- / 4 <22 E
6. Truang Dal hoc Y khoa Hu6 z 0,5-4 332 62_69
7. TmOng Dai hoc Y Dugc CA.n. The"
04-4 0 3761022_4 - L22.0
8. Truong Dai hoc Y Pham. Ng9c Thach :
9, Tnro-ng Dal hoc Dieu throng Narri Dinh : 0 55G 36q-9-6- 03s-0 36q-3669
10. True-rig Dai hoc Ky thu-at y t6 Ha.z Ducmg : 03 20 3 H A'' 9T11.Tnro-ng Dai hoc K-y thut y Dugc Da N'Lg O5 4 4 3 ' 3 S 3 go
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Danh sach (loan chi Nhtit Ban thAng 10/2014 then chtro-ng trInh JENESY 2.0
Gi6i
fink
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28/08/1990
01695770756
thalhahaiphong
@yahoo.corn
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27/02/1990 '
01263356688
thanhhai270290@grnall.com
MY
05/11/1992
Nit
19/09/1991
Ncr
09/08/1991
01649823590
vanihiminhan@gmail.com
Nit
14/08/1993
01648108075
nniatuyet.1441993 @gi nail.cona
HO ehieu
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01656092119
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01688939265
whyisme2201@gmail.com
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1994
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No.
25/02/1989
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dtrong Nam Dinh
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23/01/1991
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01674023778
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11/12/1991
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Thai Binh
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08/05/1992
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Tran
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Pharn Ngoc Thach
CN clieu
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1988
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P. 5
NO. 127
844 846195
11. JUL. 2014 10:14
Req.No.
JENESYS2.° Entry Form for JENESYS 2.0 Programme
(Country:
1. Personal Information
* Please fill in the form in BLOCK LETTERS.
Full Name(Exattly the same as your passport) (in English)
Photo
(taken within 3
months)
Please write
your name on
the back of
your photo.
.Family Name (English)
Given name (English)
Middle Name (English) (if any)
___,
1-.
;
,
.
Full Name (in Mother language)
--
(Day)
Date of Birth
Month)
Year
...______.
A,ge (as or the
1
1
as shown on your
1
passport)
starting day of
the programme))
1
Nationality
Religion
.
Name
Sex
1111 Buddhist
Christian ( [=1 Sornan
Hindu
Ni Muslim
Protesta,
111 Other
0 Single
Marital Status
Number
___._..
.
,
Diplomat
Private
Passport**
Date of Issue
_._ .
Mamie.
Type of Passport
..
Date of Expin,
._
.
IN Fema
Others
Mother Tongue
(Day)
Male
(Month)
(Year)
;
(Day)
Official
.... .....
.
._._____
(Month)
'
(Year)
I.
l
,
I
Address
--
_...... ___....._ .
... ____ .
.
.._____ ____
Current Address
Tel:
__ .. .___.
..
- -••""
r-Ad—d-ress
blank.
Tel:
_ .. .
- •—•
--
-
. .
-
- -- -
-- -
•
Full Name
•• • - - - - • —
.. . .
Phone Number:
.
-
.
•
•
•
.
•
•
--• • •
• --•• •
:Relationship
_._ __ ._ . ..
I
I
•
• • • •• • - •
• •-•----•-•----
_
.
;
. __
'Fax:
.
•
Mobile:
.... _ ___. . .
... .. _.
Profession/Occupation:
"If you do not have
phone atyour current
address, please write
contact person and
number.
•• . - -
- -- •
in'Emer_d
it shall be your parent.
If you live with him/her,
please leave address
•
E-mail:
Full Name
...
______
_....
C ontact Person
•
Fax:
.
Mobile:
... - ...
.
....
i E-mail:
.
.
___
..
•
-
'Relationship
.
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
JUL, 2014 10:14
NO. 127
844 846195
P. 6
2. Health Condition
Blood Type
❑ A
❑6
❑0
❑ AE
U UNKNOWN
II Good
Health Condition
... ._ .
l-laving Chronic disease
Please specify:
[chronic lung disease (asthma, chronic obstructive lung disease etc.)
[immunodeficiency state (T cell immunodeficiency etc.)
Dchronic heart disease (congenital heart disease, coronary artery disease etc.)
Dmetabolic disease (diabeteQ Crenal dysfuncfjn CobEity El myasthenia gravis
Dinfectious diseases (Specified:
)
Clothers (
)
1. A permission letter by doctor is required in the pre-departure orientation.
2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.
❑ Not taking any medicines
Medicine
ETaking medicines regularity (Specified:
Pregnancy
Food Allergies
(which may cause
allergic reaction)
OYes
nNo
cannot participate in JENESYS 2.0 Programme
*Pregnant women
owing to maternal and child health reason.
MINone
ill Shrimp DCrab MOShellfishO OFisf:
i—i Others (
Li
alone
Food Restriction
(for religion or
custom reason)
Dietary
Requirements
Other Allergies and
Restriction
)
MIPork
... . ......
CEgg
• -- - - - - •
C1Shrir0
ClOt
-• -
En Beef LOChickerEl EIMutton/LarrO
• --- -- - -- ---- - 111Shelifish
INFish EEgg FIlOthers (
)
'Please be noted that the meals provided in the programme cannot meet all the requests from the participants.
UNone
EiVegitarian EUVegann OHaIC DOthers
)
L None
. . .
. . .... .. . ..
❑ Dogs E Cats DilHouse dust: DOthers (
. .
. .
.
_
..
)
3. Academic Details and Professions
Location (c ty,province)
Name of Organization
Tel:
1
1
,
•
.
Fax:
Profession (for non-student onll
Information of your
Field of study (for
School/Organization
university student only)
_.
.,... .........___ ____ . ...__ .. !
• --.
.
Grade/school year (for
student)
as of the day of the flight to
..
. .... . . _. . ._ .
Title (for supervisor only)
....
. _._,
-- - - ----- - •
----
--
•
.. .
.
- ••
•
•
English Proficiency
certificated score (if any, e.g.
Level
_ ...___. of Japanese
•-• - •--- --
Speaking ❑ Good ❑
Faill
Poor
Fai:-.1
Writing
iiil Good II
Poor
.. .....__ .
Fai❑
Reading 1.11 Good •
Poor
Japanese
Year or Month
Poor
Level of English
..._______ ......._ ..._ ....
Language
Fau
Speaking ❑ Good IN
._.. _ . ..._ ... .. _
..
Fairi
Writing :1 Good 0
Reading :❑ Good
Other
Language
.
Ej
Faim
Poor
learning
experience
I
Poor
__ --
Revised on 20/11/2013
11. JUL. 2014 10:14
NO. 127
844 846195
4. Personal Activities
Activities
P. 7
Period of Involvement
Sports/Clubs
Hobbies
Academic Awards
(if any)
5. Essay
*Please answer the two auestions in 250 - 300 words. You
171Av AffPrh
nanwq ac naori,,r1
1. Why do you want
to participate in the
JENESYS 2.0
Programme?
2. What will you be
able to contribute to
it?
6. Other Information
Have you ever been to Japan before El Yes
0 No
If Yes, When?
.
.
.
If Yes, what was the purpose of
the visit and where did you visit?
principle, any candidates who have participated in JENESYS 2.0 Programme 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.
Agreement of the Application Guidelines for JENESYS 2.0
I have read and understood the terms and conditions in the "Application guidelines for JENESYS 2.0."
Agreement of the Handling of Personal Information
agree that my personal information in the Entry Form
will be used in accordance with the Handing of Personal Information (ANNEX).
(Day) (Month) (Year)
Signature:
Date:
ANNEX
Revised on 20/11/2013
.11. JUL. 2014 10:14
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NO. 127
P.
8
With re arid to the Handling of Personal Information
(Managed by Japan Overseas Cooperative Association, for Jenesys2.0 appLcants)
The Association observes the laws and ordinances of Japan, principles, guidelines and other
regulations determined by the government with regard to protection of personal information. As
to JENESY52.0, in order to ensure the actions are in accordance with these guidelines, please
agree with the following points and submit the application_
Nose
1 intended Purposes
The purposes of the personal information you provide are intended to be for recruitment,
selection, program participation procedures, and report of achievement of the program (including
for public relations regarding the project on the Association's home page and bulletin) as to
JENESYS2_0 ASEAN Short-Term Invitaton Project. Collected information will not be used for
other purposes_
2 Entrustment of Personal information
Personal information you provide may be entrusted to travel agencies, insurance agents, or
printing companies with which the Association may contract.
3 Provision to Third Parties
Personal information you provide may be shared with third parties in order to smoothly
manage the program or report achievement o; the project.
(Entities to which the personal information will be provided) Ministry of Foreign Affairs of Japan,
ASEAN, partner exchange schools, host families, etc.
(information to be provided) 1Vlattrs described in applications, passport information
4 Voluntariness of the Provision of Personal Information
Your personal information is to be provided voluntarily_ However, your non-provision of
necessary information may result in difficulties upon participation in the program.
5 Disclosures, Corrections, Additions. Deletions, etc. of Personal Information
You have the right to request notice of the intended purpose, disclosure, and correction of
personal information, addition and deletion of some terns of information, and the deletion, dist_isP,
and suspension of use of the personal information itself_ When you wish to request disclosure
of your perscnw information, etc., please contact the following consultation service
representntive.
[Personal information Consultation Service Representative)
5'11 Floor, Nirlonseimei lchibancho Building., 23-3 lchiban-oho, ChiyoCa, Tokyo, 102-0082
General Affairs Department of Japan Overseas Cooperative Association. contact for Personal
Information Consultation Services: Daisuke Watanabe
Email : kojinjoho@joca,or.jp
Tel ; 03-6261-0261
(Contact Information as to JENESYS2.0]
Japan Overseas Cooperative Association. Third DiVision of Operator! Department, Division
in charge of JENESYS..20
Tel : 03-62'31-0247 FAX 03-6261-0249
Email . bunka3(ajoca_orjp
Revised on
20/11/2013
JUL. 2014 10:14
NO. 127
844 846195
P. 9
JENESYSI°
JENESYS2.0 PARTICIPATION AGREEMENT
TERMS AND CONDITIONS
I
(name)
hereby acknowledge that I understand and agree to the following terms and conditions
regarding my participation in JENESYS2.0.
All participants including chaperons/supervisors will need to be physically fit and
capable of walking extensive distances and climbing numerous stairs. Candidates with
medical conditions which may impede full participation in physical activities should not
be considered.
Each participant must declare all the health problems in the application form and is
fully responsible for health condition and its costs associated with those diseases.
Participants including chaperons/supervisors have to comprehend that medical
treatment cost related to the chronic disease is not covered by the program insurance.
Airfare, lodging, transportation, meals and admission fees for scheduled activities are
provided for all JENESYS2.0 participants. Participants are expected to cover personal
expenses and bring sufficient funds for pocket money and for the purchase of items for
personal use.
A participant is fully responsible for costs associated with last-minute cancellations or
changes, initiated by the participant.
Participants with behavioral issues may result in dismissal from the JENESYS2.0
program and leave Japan at their own expense.
All participants including chaperons/supervisors have to attend all the programs
planned by the implementing agency and they need to follow the rules/guidelines made
by the implementing agency.
(Signature)
(DD) (Ivan (YYYY)
11. JUL. 2014 10:14
- •
844 846195
NO. 127
P. 10
VISA APPLICATION FORM TO ENTER JAPAN
(Paste photo here)
45mm x45mm
*Official use only
or 2inx2in
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)
Place of birth
Date of birth
(Day)/(r onth)J(Year)
Sex: Male 0 Female
7
(City)
(Country)
(State or ProvinceT
Marital status: Single 1:11 Married 0 Widowed El
Divorced
Nationality or citizenship
Former and/or other nationalities or citizenships
ID No. issued to you by your government
Passport type: Diplomatic E Official
E
Ordinary ❑ Other
❑
Passport No.
Date of issue
Date of expiry (Day)/(Month)/(Year)
Place of issue
authority
(Day)/(Month)/(Year)
Purpose of visit to Japan
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.
Name
Address
Dates and duration of previous stays in Japan
Your current residential address (if you have more than one address, please list them all)
Address
Tel.
Mobile No,
Current profession or occupation and position
Name and address of employer
Name
Address
Tel.
1'. JUL 2014 10:4
844 846195
NO. 127
P. 11
*Partner's profession/occupation (or that of parents, if applicant is a minor):
Guarantor or reference in Japan (PloseProOde details ofthe guarantor or the person to be visited in Japan)
Name
s
:
••
Tel.
%. •
Address
Date of birth
Sex: Male
El
Female
❑
(Day)/(Month}/(Year) •
Relationship to applicant
Profession or occupation and Oosition
Nationality and immigratiorist4us
Inviter in Japan(Please write 'same as al;ovi!lf the inviting person and the guarantor are the same)
Name
Tel.
Address
Sex: Male 0 Female
Date of birth
(pay)/(Month)/(Year)
Relationship to applicant
Profession or occupation and position
Nationality and immigration status
*Remarks/Special circumstances, if any
Have you ever:
No
n
• been convicted of a crime or offence in any country?
Yes ❑
• been sentenced to imprisonment for 1 year or more in any country?**
Yes 171 No
• been deported or removed from Japan or any country for overstaying your visa or violating
any law or regulation?
Yes El No 171
• been convicted and sentenced fora drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances?**
Yes IE
• engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
persons, or in the provision of a place for prostitution, or any other activity directly
connected to prostitution?
• committed trafficking in persons or incited or aided another to commit such an offence?
** Please
E
No
7
No 1:
Yes E
No 0
Yes
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.
1 hereby declare that the statement given above is true and correct-1 understand that immigration status and period of stay to
be granted are decided by 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."
"I 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 fee to the
Japanese embassy/consulate-general, when such payment is necessary."
Signature of applicant
Date of application
(Day)/(Month)/(Year)
It 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 Personal Information") will be handled appropriately in accordance with the Act on the
Protection of Personal Information Held by Administrative Organs (Act No. 53 of 2003, hereinafter, "the Act-")- Retained Personal
Information will only be used for the purpose of processing the visa application and to the extent necessary for the purposes
stated in Article 8 of the Act.