CONG HOA XA HOI CHI` NGHIA VIET NAM DO`c lap - Tu. do

CONG HOA XA HOI CHI' NGHIA VIET NAM
DO'c lap - Tu. do - Hanh phtic
4520 /BYT-QT
PG
•.
trinh JENESY2.0
, 11.•o
HQC Y DU% TP.HCM
DEN
; Chuyen.
Ha N0i, ngdy ,14 dicing 7 aim 2014
Kinh
s6. 4G?
cu
Y ObtC3c
le)
MAnev
. gQf4-
Lien. uan an chucmg trinh giao km JENESY danh cho sinh vien y khoa
a 'lieu duoing dm Vi'4 Nam sang Nh4t Ban, BC) Y to da nh4n dugc danh sach
cac sinh vien do qu5T Trueng & cu tham gia chucmg tint'. D6" hoan tat cac thu
tuc tip theo, BO Y t6 cue n 1 cac truOng c6 sinh vien tham dir:
Cung cap cac thong tin lien quan dm sinh vien dugc cu tham du
L chuong trinh theo triAil giri kern theo.
Thong bao cho sinh vien lam h"(5 chi6u ph6 thong va hoan thin cac
form danglc3"1 sau: Form dOng3'1 tham gia chuong trinh, Form gang Ic3r7
tham gia chucmg trinh JENESYS 2.0, Form cap visa vao Nh4t Ban
(cac form dugc clan anh va day du chit k)'/). D&' nghi sinh vien tract tip
lien 11" yeti Vu Hop tac Qu6c to 6'' dugc huong dgn khai form va. nh4n
ban mem qua email. Cac form clang 14/ va ban g6c ho chi6u n'(5p v'e Vu
Hop tac Qu6c to truck ngay 5/8/2014.
Ve tiled gian: Ban to chirc c6 th6ng bao thoi gian di Nh4t Ban co su
thay d6i nhu. sau: tir ngay 21-29/10/2014.
Kinh phi: Ban to chirc dai tho toan b(i kinh phi, ye may bay, an O., di
14i cho sinh vien tai Nh4t Ban. Cac kinh phi khac truoc chuyen di nhu
111,5 chiL, an 6., di lai tir dia phuong an san bay que)c t6 N's:.i MI/Tan
Son Nhdt do ca nhan to tut hoc Truong dr sinh vial tham du h8 trq.
B6 Y te' tran trong thong bao de qu3'T Truong bit va thOng bao d6n cac
sinh vien hoan tat cac thu tuc cho chuy6n di.
Noi nhem:
- Nhtr ten;
- TT. Le Quang Ctrong (c16' b/c);
- Ltru: VT, QT.
TL.B0 TRUbNG
KT. VU TRUbNq,-VIV MP TAC QUOC TE
/13H45,VJU liONG
(Ng
iv
uygn I„N14nh Ctro.ng
Moi thong tin chi tit lien he: Ms. Vu Ha Thu (DD:0912020382, email: [email protected] )
Danh sach down di Nh4t Ban thang 10/2014 theo chtrang trinh JENESY 2.0
STT
119 NI ten
1
Nguyen Thai HA
2
Pham Thanh Hai
3
Nguy6n HuSlnh Ai
Uyen
4
D8 Thi Di8m Ngoc
Dai hoc Y Duvc
Can Thos
5
Van Thi Minh An
Dai hoc Y Dtrot
A
Hue
6
TO Thi Lien
Dai hoc Y Duvc
Hue
7
Nguy8n Thi Tam LS,
Dai hoc Y Ha N6i
8
Nguy8n Thi Nhung
Dai hoc Y Ha N6i
9
Le Thi Huy'en
10
Phung Thi Hong Ha
11
Iran Thi Thu Dung
Truirng
Dai hoc Y DU'Qt
Hai PhOng
Dai hoc Y Duvc
Hai Phong
Dai hoc Y Duvc
Can Tha
Dai hoc Y DuvcDai hoc Thai
Nguyen
Dai hoc Y th.rotDai hoc Thai
Nguyen
Dai hoc Y Duct
TP. HO Chi Minh
Chuyen
nginh
Y nam thir 4
CN Di8u
Mang nam
thir 3
SV Y khoa
nam thir 5
SV di8u
rang nam
thir 3
Da khoa
nam thir 5
Da khoa
ram thin 3
Y hoc dig!.
ph6ng nam
thir 3
CN di8u
&rang nam
thir 4
CN dreu
dtriefrng
Gbfri
tinh
NO), sinh
Nil
Si din thoai
Email
28/08/1990
01695770756
thaihahaiphong
@yahoo.com
Nit
27/02/1990
01263356688
[email protected]
Nil
05/11/1992
Nir
19/09/1991
Nir
09/08/1991
01649823590
[email protected]
Nit
14/08/1993
01648108075
[email protected]
Hi) chieu
Nit
01656092119
Nir
01647549606
Na
14/10/1993
01659990280
[email protected]
Nil
22/01/1993
01688939265
[email protected]
Nur
1987
12
Pham Ngoc Thuy
Trang
HoangDung
14
Nguyen Thi Loan
15
Pham Thi Bich Ngoc
16
Vu Hang Nhung
17
Nguyen Thi Thu
Hu6ng
18
Vu Thi Quyen
19
Nguyen Thi Kieu
20
WI H6ng Son
21
22
23
24
25
Quan Thi Thanh
Thily
Nguyen Thi Que
Tran
Nguyen VO Minh
Trang
Pham Ngan Giang
Dai hoc Y Comic
TP. H6 Chi Minh
Dai hoc K57 thuat
Y-Duot Da Nang
Y
D-apitrha
oc K
D Ss%a N
t hatinagt
Bac si
Dai hoc Dieu
&ging Nam Dinh
ditighN
ocam
DiD
etiinh
Cr nhan
dieu ding
i
Lur dnu
hang
tn
Dai hoc Dieu
duOng Nam Dinh
Dai hoc K57 thu4t Y
to Hai Ducmg
Dait6hH
ocaiKiLto.n
hu:
Y
Cunhan
dieu dutng
Dai hoc Y Duorc
Thai Binh
Dai hoc Y Dugc
Thai Binh
Dai hoc Y khoa
Pham Ngoc Thach
Dai hoc Y khoa
Pham Ngoc Thach
Cyc KHCN&DT
B6 Y to
Vu HTQT
B6 Y te
CN dieu
ducrng
Bac si da
khoa
Chanh Van
ph6ng Cyc
Nu
1987
N
Nu
1992
Nil
1994
Nu
25/02/1989
Nil
23/01/1991
Nit
06/06/1989
Nil
0976217809
[email protected]
Nit
01674023778
[email protected]
Nam
11/12/1991
Nir
08/05/1992
Na
No.
xTri.
—4
Nil
1988
1987
0913593736
JENESYS2°
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) (MM) (YYYY)
Req.No.
jENESYS2° Entry Form for JENESYS 2.0 Programme
(Country:
1. Personal Information
* Please fill in the form in BLOCK LETTERS.
Full Name (Exactly the same as your passport) (in English)
Photo
(taken within 3
months)
Please write
your name on
the back of
your photo.
Name
Family Name (English)
Given name (English)
Middle Name (English) (if any)
Full Name (in Mother language)
(Year)
(Month)
(Day)
Date of Birth
(as shown on your
passport)
Age
(as of the
starting day of
the programme)
Sex
Nationality
Religion
❑ Buddhist
❑ Christian ( ❑ Roman ❑ Protestai
❑ Hindu
❑ Muslim
❑ Others
❑ Other
❑ Fema
)
)
(
Marital Status
Mother Tongue
❑ Male
Number
❑
Single
❑ Marne,
Type of Passport
❑ Private
❑ Diplomat
❑ Official
Passport**
Date of Expiry_
Date of Issue
(Day)
(Month)
(Year)
(Day)
(Month)
}
- -
(Year)
Address
Current Address
Tel:
Fax:
Mobile:
E-mail:
1Relationship
Full Name
Contact Person
in Emerqency
—
Address
*It shall be your parent.
*If you live with him/her,
please leave address
Tel:
blank.
Mobile:
Fax:
E-mail:
Profession/Occupation:
*If you do not have
phone at your current
address, please write
contact person and
number.
Full Name
, Relationship
I
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
❑
A
❑B
❑0
❑ AE
❑ UNKNOWN
❑ Good
Health Condition
— Having Chronic disease
Please specify:
Ochronic lung disease (asthma, chronic obstructive lung disease etc.)
Jimmunodeficiency state (T cell immunodeficiency etc.)
chronic heart disease (congenital heart disease, coronary artery disease etc.)
Dmetabolic disease (diabete0 Elrenal dysfuncOn DobDity lilmyasthenia gravis
Dinfectious diseases (Specified:
)
)
mothers (
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.
Medicine
Pregnancy
Food Allergies
(which may cause
allergic reaction)
Food Restriction
(for religion or
custom reason)
❑ Not taking any medicines
❑ Taking medicines regularlly (specified:
❑ Yes
01No
)
*Pregnant women cannot participate in JENESYS 2.0 Programme
owing to maternal and child health reason.
❑ None
❑ Shrimp DCrab ❑0ShellfishEl 1=1FisE 1=IEgg
❑ Others (
)
❑ None
❑ Pork alBeef ❑ClChickeril ElMutton/LamE
EShrirEl
0(03b
❑ Fish DEgg EnOthers (
OShellfish
)
*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.
Dietary
Requirements
MNone
DVegitarian IIIVegan❑ DHalC ElOthers (
)
Other Allergies and ❑ None
Restriction
❑ Dogs CrICats EDHouse dustill 1110thers (
)
3. Academic Details and Professions
'Location (city,province)
Name of Organization
Tel:
Fax:
Profession (for non-student onl
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
Level of English
Language
Speaking ❑ Good ❑
Fail]
Poor
Speaking ❑ Good ❑
Fai❑
Poor
:❑ Good ❑
FaiL
Poor
Writing
fl Good ❑
Fai❑
Poor
Reading :❑ Good ❑
Fai❑
Poor
Reading 0 Good ❑
Fai❑
Poor
Writing
Other
Language
Japanese
Year or Month
learning
experience
Revised on 20/11/2013
4. Personal Activities
Period of Involvement
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.
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 befon
❑ 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 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
I 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
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)
Date of birth
Place of birth
(Day)/(Month)/(Year)
Sex: Male
Female
E
(City)
Marital status: Single
(Country)
(State or Province)
Married
Widowed H Divorced
a
Nationality or citizenship
Former and/or other nationalities or citizenships
ID No. issued to you by your government
Passport type: Diplomatic —1 Official
Ordinary
Other n
Passport No.
Place of issue
Date of issue
Issuing authority
Date of expiry
(Day)/(Month)/(Year)
(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.
•
*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)
Tel.
Name
Address
Sex: Male
Date of birth
Female
ri
(Day)/(Month)/(Year)
Relationship to applicant
Profession or occupation and position
Nationality and immigration status
Inviter in
Ja pa rl(Please write 'same as above' if the inviting person and the guarantor are the same)
Tel.
Name
Address
Sex: Male 11 Female
Date of birth
(Day)/(Month)/(Year)
Relationship to applicant
Profession or occupation and position
Nationality and immigration status
*Remarks/Special circumstances, if any
Have you ever:
• been convicted of a crime or offence in any country?
Yes
• been sentenced to imprisonment for 1 year or more in any country?**
Yes
• been deported or removed from Japan or any country for overstaying your visa or violating
any law or regulation?
Yes r
--1
Non
• been convicted and sentenced for a drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances?**
Yes El
No ❑
• 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?
Yes
Yes
No
Ei
E
E
No
No
E
No
** 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.
'I hereby declare that the statement given above is true and correct. I 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. 58 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.