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 JFY2024
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 (JICA Knowledge Co-Creation Program)(KCCP)
(JICA Development Studies Program)
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APPLICATION FORM
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Reg.No
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Instructions
1. Fill-in all YELLOW areas (or cells) of this form by computer. (DO NOT handwrite.).
2. Fill in the form in English.
3. All YELLOW areas MUST be filled-in (Do not leave these areas blank. Please write "N/A" if not applicable).
4. Write dates in the order of day, month, year (ex.: 31st day of January, 2023 is "31/Jan/2023").
5. Write proper nouns in full without abbreviation.
6. Check your application form using the check lists at the bottom of this application form.
7. Print out all pages after entering required information in all questions.
8. Obtain Signature(s) of the applicant's present organization (if necessary, digital stamp/signature is acceptable.).
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1. Personal Information
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1-1. Course
Color Photo
(4cm×3cm)

Paste your photo
taken within
6 months.
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1-2. Number (Not need to fill in. JICA will inform after selection Procedures)
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1-3. Information about the applicant
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Family Name
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First Name
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Other Name
(If any)
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Gender
for Visa application		Date of Birth
(Day/Month/Year)		//
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NationalityAge
(As of 1/Apr/2024)
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Resident Country
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City/TownTEL
(Primary)		Country Code
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State/ProvinceTEL
(Secondary)		Country Code
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EmailPassport possession
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1-4. Contact Person in Emergency (2 Persons)
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1NameRelationship
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Province & CountryTELCountry CodeEmail
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2NameRelationship
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Province & CountryTELCountry CodeEmail
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2. Educational Background (Higher Education)
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 Name of Educational InstitutionProvince, CountryFrom (Month) / (Year)
To (Month) / (Year)		Type of Academic Degree
Obtained		Major
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Name of Faculty / Department / School
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From/
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To/
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From/
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To/
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From/
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To/
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From/
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To/
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If the period you have entered in 2. Educational Background above does not match a regular academic period, please indicate your reason in "Remarks" below.
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Remarks
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1)
Language Proficiency
Indicate your English abilities with reference to the following.
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English ProficiencyListening
Excellent:




Good:



Fair:



Poor:

Refined fluency skills and topic-controlled discussions, debates & presentations. Formulates strategies to deal with various essay types, including narrative, comparison, cause-effect & argumentative essays.

Conversational accuracy & fluency in a wide range of situations: discussions, short presentations & interviews. Compound complex sentences. Extended essay formation.

Broader range of language related to expressing opinions, giving advice, making suggestions. Limited compound and complex sentences & expanded paragraph formation.

Simple conversation level, such as self-introduction, brief question & answer using the present and past tenses.
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Speaking
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Reading
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Writing
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Certificate
(Please specify Name of Cetificate)
ex.: TOEFL, IELTS		Not decided
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If Others, specify
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 Score points obtainedSee above
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Test DatesDayMonthYear
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 Your Mother Tongue