Attachment B

JPO/IPR Training Application Form

FY 2018
Please use this form for the courses in the fiscal year 2018; the
forms of the previous years are not acceptable.

THIS APPLICATION CONSISTS OF SIX PARTS:

【PART 1】 Guarantee of Applicant by Company/Organization (page 1)

【PART 2】 Applicant's Personal History (pages 2, 3 and 4)

【PART 3】 Reasons for Applying (pages 5 and 6)

【PART 4】 Medical Check Sheet (page 7)

【PART 5】 Overseas Travel Insurance Procedure and Consent Form (pages 8 and 9)

【PART 6】 About the Handling of Personal Information Concerning Trainees (page 10)

INSTRUCTIONS: Please read carefully before completing this form.

1. All sections should be completed. If an item does not apply to you, please write "N/A" in the space
provided. If your application is incomplete or inaccurate, JPO, JIPII and AOTS may not accept your
candidacy.

2. Type in information to complete the entire form in English and tick the appropriate boxes.

3. Be careful about the submission deadline. JPO, JIPII and AOTS may not accept your candidacy if your
application reaches us after the due date.

4. PART 1 should be completed by the representative of the applicant's company/organization (not by the
actual applicant).

5. PARTs 2 through 6 should be completed by the applicant.

6. PART 2 E-mail, Fax Number, and Telephone Number must be filled in clearly to allow AOTS to contact
you.
 JPO/IPR Training Program　FY 2018 Part 1

【PART 1】Guarantee of Applicant by Company/Organization

To be completed by the representative of the applicant's company/organization (not by actual applicant).

TO: Mr. Shinya KUWAYAMA

President
The Association for Overseas Technical Cooperation and Sustainable Partnerships (AOTS)

I, the representative of applicant's company/organization, would hereby like to nominate

the person below to participate in a training program in Japan, which is organized by the
Japan Patent Office, and certify that:

- the applicant meets all conditions and requirements for participation described in the
General
　 Information (GI) on the JPO/IPR Training Program FY 2018;
- the applicant will follow the organizer's standards and directions;
- all information provided on this application form by the applicant is complete and correct.
If he/she does not complete the training program and returns home prior to completion, I
agree to reimburse all actual expenses including air fare, accommodation fees, etc.

Name of Applicant:

Name of Training Course:

Training Period (DD/MM/YY): from: to

I hereby give my approval for the applicant to be sent to Japan as a participant of the program
indicated above.

Name: Position:

Representative of Applicant's Company/Organization

Company/
Organization:

Phone*:
E-mail*: @
Fax*:
* Please provide the above contact information as it may be necessary to contact you in an emergency.

Signature: Date (DD/MM/YYYY):

　　　　◆Privacy Policy of AOTS: The purpose of use of personal information

JPO/IPR Training Program　FY 2018 Part 1

1. Based on the "Act on the Protection of Personal Information", AOTS will use applicants' personal information only

for the administration procedure of AOTS Training Programs and some other related purposes.

2. AOTS secures personal information in an appropriate manner against loss, misuse or improper alternation.

3. AOTS strictly observes all applicable Japanese laws regarding the handling of all personal information that it receives.

Page 1
 JPO/IPR Training Program　FY 2018 Part 2-1

【Part 2】 Applicant's Personal History

To be completed by the applicant

(Please attach a
1. Personal Information photograph of your
1-1 1-1(1) face HERE.)
Name of the First Name
Applicant 1-1(2)
Middle Name
*Your name must be
the same as the name 1-1(3)
in your passport. Family Name
Your suggested name within 30 letters:
If there are over 31 letters in your full name including the space
between names, you are requested to suggest how to write
your name within a maximum of 30 letters. AOTS will issue
documents for your travel according to your suggestion.

1-2 1-3 Day/Month/Year 1-4

Gender　 Date of Birth Age
(Male/Female) ／ ／
1-5
Religion Christian / Muslim / Buddhist / Hindu / Other / None

1-6
Name of Building:
Home Address
Street: City:

State: Postal Code: Country:

1-7 Home Phone 1-8 Mobile Phone
+ +
Number Number
1-9
Your Personal E-mail @
1-10 Do you have a passport? 1-11 Day/ Month/ Year
Passport Date of Issue
Yes* personal service ／ ／
No 1-12 Day/ Month/ Year
Date of Expiry
*If yes, please attach a copy of your passport. ／ ／
1-13 Do you have a USA Visa? 1-14 Day/ Month/ Year
USA Visa Date of Issue
(For applicants from Yes* No ／ ／
Latin America) 1-15 Day/ Month/ Year
*If yes, please attach a copy of your USA Visa.
(To be used for flight arrangements) Date of Expiry
／ ／
1-16 1-17
Nationality Your Home Airport
This should be the international airport nearest
to your address.

2. Company / Organization Information

2-1 Please fill in the name of your company/organization as on your business card.
Name of Company/
Organization

2-2
Department/ Section

2-3 This is a contact address for AOTS . Please give the address where you actually work.
Company /
Organization Name of Building:
Address
Street: City:

State: Postal Code: Country:

2-4 Office Phone 2-5
Number (including + Office Fax Number +
ext.)
2-6 2-7
Your Office E-mail @ Business Field
 JPO/IPR Training Program　FY 2018 Part 2-1

2-8
Major Products/
Service

2-9 2-10
Year of Establishment Number of Employees

Page 2
JPO/IPR Training Program　FY 2018 Part 2-2

2. Company / Organization Information (cont'd)

2-11 Please select "Public Sector" or "Private Sector", and then the appropriate category from the list.
Type of Organization Public Sector Private Sector ###

Government Office Law Firm

Government Corporation Manufacturing Company
Research and Development Institution Academic
Academic Industry Promotion Organization
Other (please specify below): Other (please specify below):

Government O
3. Career Information Government C

Please complete sections 1 and 2 below if applicable.

Classification of Your
Qualifications and/or 3-1 If you work at an IP Office, indicate your qualification from the list, as well as years of experience.
Position/Job Title
For IP Office Officer Other (please
Examiner Years of Your Experience Law Firm
Patent Formality Examination ( years )
Utility Model Classification Assignment Academic
Design Substantive Examination ( years )
Trademark Prior Art Search ( years )
Appeal Examiner Preparing Search Reports
Patent Making Decisions on Patentability/Registrability
Utility Model Appeal/Trial Examination
Design Promotion of IP information( years )
Trademark Automation System Development / Maintenance
Administrator ( years )
Other (please specify below): Other (please specify below):

3-2 Indicate your qualification from the list below (Check all the qualifications/certificates you possess).
Licensed / Registered Public Position
Lawyer Judge
Patent Attorney
Patent Agent Public Prosecutor
IP Agent
IP Attorney
IP Consultant
Other (please specify below):

4. For Applicants Participating in One of the Following Courses

JPO/IPR Training Course for IP Protection Lawyers
　　　 Please choose which group you would like to participate in.
Patent Group Trademark Group

JPO/IPR Training Course for Practitioners Specializing in Patents

Do you have experience drafting "patent specifications?"
Yes No

JPO/IPR Training Course on Anti-Counterfeiting for Practitioners

Do you engage in work related to counterfeits and piracy?
Yes No

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JPO/IPR Training Program　FY 2018 Part 2-3

5. Educational Background (Higher education)

Period
Name of
From To Degree Major Language Used
University/Institution
Month/Year Month/Year

／ ／

／ ／

6. Work Experience Related to IPR Please list your work experiences that are related to IPR ONLY.

6-1　Name of Organization Years of Service Position Main Responsibilities

From To
Month/Year 　　　Present
(See 【Part 3】, 2-4) (See 【Part 3】, 2-5)
／
From To
Month/Year Month/Year
／ ／
From To
Month/Year Month/Year
／ ／
From To
Month/Year Month/Year
／ ／
6-2 Years of total work
years
experience related to IPR

7. Language Proficiency
English* Please indicate your language proficiency. English Score:** Year of Acquisition:

A: Able to actively participate in debates TOEIC:

TOEFL:
B: Able to follow lectures well &participate in discussion
Other:

C: Able to follow much of lectures Name of the test:

D: Able to carry out daily conversation None
* If English proficiency is considered to perhaps be insufficient, an interview will be conducted by telephone.
** If you have any of the English test scores, please attach the certified score sheet.

8. Past Experience of the HIDA/AOTS Training in Japan YES NO

1st Time 2nd Time 3rd Time
HIDA（AOTS) Training Course
Example: 6W, PQM, IPPP, etc.

HIDA(AOTS) Membership No.

Day/Month/Year Day/Month/Year Day/Month/Year

From
／ ／ ／ ／ ／ ／
Training Period
Day/Month/Year Day/Month/Year Day/Month/Year
To
／ ／ ／ ／ ／ ／
Training Field/Technique

Name of Host Company

9. Experience of Study or Training Abroad (within 5 years) YES NO

Country Period of Stay Purpose Language

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 JPO/IPR Training Program　FY 2018 Part 3

【PART 3】 Reasons for Applying

● Please answer the following items in English and submit it to AOTS with the other specified documents.
● This document will be used as reference material for the screening committee in selecting the participants.
● In addition, participants of some training courses may be requested to make a presentation based on this document.
● If you use any figures or statistics, please indicate the source of such data.

1. Name of the Training Course

2. Personal Information

2-1 Your Name

2-2 Country

2-3 Company/Organization

2-4 Position & Department

2-5 Main Responsibilities in Detail

　 (Please describe these with a focus on the required qualifications targeted for the course.)

3. Organizational Chart in English

Please provide the Organizational Chart in English.
● Please write the URL (link) to the organizational chart in English in the area below, if available.
Also write the name of the department in which you currently work.
● If an online chart is not available, please attach a hard copy of the chart to this document, or draw one in the area below.
Be sure to indicate your department in the chart with an arrow (->).
URL: http://www.
 JPO/IPR Training Program　FY 2018 Part 3

URL: http://www.

Page 5
 JPO/IPR Training Program　FY 2018 Part 3

4. The most critical problems related to IPR you are now facing on. Please describe these with a focus
matters related to the course objectives.

5. Your expectations of the program, and how you intend to apply what you gain from this course when
you return home.

I certify that the information I provided in this JPO/IPR Training Application Form FY
2018 is complete and correct to the best of my knowledge.

Applicant's Signature Date (MM/DD/YYYY)

JPO/IPR Training Program　FY 2018 Part 3

Page 6
 JPO/IPR Training Program FY 2018 Part 4

【PART 4】 Medical Check Sheet

Your Name Course Name
［Important Notice］
AOTS will not provide financial assistance for diseases that you knowingly had or contracted before visiting Japan. If you have a chronic
disease, you should bring your medicine with you when travelling to Japan. If there are any false or wrong statements on this sheet, the
overseas travel accident insurance, which the trainee will subscribe to upon arriving in Japan, will be invalid.

1. If any of the medical conditions listed below apply to you, select "X" from the pull-down menu in the "Yes" box, as well as the
applicable conditions on the right. If none of the conditions apply to you, select "X" in the "No" box. Complete all boxes from a to k
(l).*
Yes* No Existing Medical Conditions
a asthma emphysema other lung conditions

b tuberculosis live with someone who has tuberculosis

c high blood pressure heart disease irregular heartbeat

d stomach ulcer hepatitis inflammation of the gall bladder gall stones pancreatitis

e kidney or bladder trouble stones or blood in urine

f diabetes gout

g depression neurosis

h tumor malignant tumor cancer

i bleeding disorder blood disease

j lumbago

k cataract glaucoma

l pregnant ( ) -month pregnant (Female only)

2. Select "X" from the pull-down menu in the appropriate box. If yes, please provide details.
Medical History Yes* No Details
a Have you had any significant or serious illness or
injuries? (If you have been hospitalized or had an
operation, give disease names, dates, etc.)
b Are you currently on any medication for treatment of a
medical condition? (Give name and dosage.)
c Are you seriously allergic to particular foods, medicines,
substances, etc.?

3. I certify that I have read the above instructions and answered all questions truly and completely to the best of my knowledge.

Date
Your Signature: (DD/MM/YYYY):

* If you answered "Yes" to any of the items in 1 or 2 above, you are requested to have a doctor fill in the doctor's medical report
below. (If you answered "No" to all items, you do not need to complete the form below.)

【FOR DOCTOR USE ONLY】

Please provide the following information concerning items in 1 and 2 above, to which the applicant answered "Yes."

1. Write the results of the medical examination as clearly as possible.

2. Indicate with an "X" in the box the most appropriate statement concerning the physical condition of the applicant.

a There is no problem with the applicant traveling and participating in a training program in Japan.

He/She must take medication, however there is no problem with the applicant traveling and participating in a training program in
b
Japan.

There is a problem with the applicant traveling and participating in a training program in Japan under his/her current physical
c
condition.

3. Fill in the following and make a signature.

Date of Diagnosis:
Name of Clinic: (DD/MM/YYYY)

Address: Name of Doctor:

Doctor's Signature:

Page 7
 JPO/IPR Training Program　FY 2018 Part 5

【PART 5】 Overseas Travel Insurance Procedure and Consent Form

Overseas Travel Insurance Procedure

THE ASSOCIATION FOR OVERSEAS TECHNICAL COOPERATION AND SUSTAINABLE PARTNERSHIPS (AOTS)
maintains overseas travel insurance coverage for all trainees as a safeguard against illness, injury, accident, or other
misfortune. The term of the insurance is limited to a fixed period approved by AOTS. The said term shall commence upon
completion of entry screening procedures following the trainee’s arrival in Japan and terminate upon completion of
exit procedures prior to the trainee’s departure from Japan.
In the event that a trainee is involved in an accident or other incident covered by the insurance, AOTS will submit an
insurance claim to the insurance company, and the insurance will be paid as follows.

1. Indemnity in the event of death: The insurance company will pay the entire sum to the trainee’s beneficiary as defined
defined under the country’s probate laws of the trainee.
under the country’s probate laws of the trainee.
2. Medical expenses: The medical facility where the trainee was treated will bill AOTS for the cost of the treatment.
The insurance company will pay the insurance benefit directly to the medical facility.
3. Insurance for disability: AOTS will pay the disabled trainee the entire sum received from the insurance company.
4. Insurance to cover liability: AOTS will pay the entire settlement to the trainee, injured party, etc., pursuant to notification
by the trainee or the training company.
5. Rescue expenses insurance benefit: AOTS will pay to the party that paid/advanced the expenses the entire sum received
from the insurance company, pursuant to notification by the trainee or the training company.

To collect an insurance benefit/settlement as specified above, trainees must submit to AOTS a consent form giving AOTS
complete authority to file insurance claims and collect benefits/settlements pursuant to this insurance policy. All trainees,
please carefully read the attached "Outline of Overseas Travel Insurance (page 9)" and sign the consent form below:

To: THE ASSOCIATION FOR OVERSEAS TECHNICAL COOPERATION AND SUSTAINABLE PARTNERSHIPS (AOTS)

Consent Form
I understand the content of the Outline of Overseas Travel Insurance. I hereby consent to being covered by an insurance
policy pursuant to AOTS training regulations. I also consent to giving AOTS complete authority to file insurance claim and
and collect insurance benefits/settlements on my behalf.

Day Month Year

Date: / /

Country/Region:

Home Address:

Trainee's Name:

Signature:

[ To be used by AOTS ]
Company: AOTS
Trainee's No.: 18IP
Training Period: from to

THE ASSOCIATION FOR OVERSEAS TECHNICAL COOPERATION AND SUSTAINABLE PARTNERSHIPS (AOTS)

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 JPO/IPR Training Program FY 2018 Part 5

Outline of Overseas Travel Insurance

THE ASSOCIATION FOR OVERSEAS TECHNICAL COOPERATION AND SUSTAINABLE PARTNERSHIPS (AOTS)
provides insurance coverage against illness, injury, or death for trainees during the training period.
The insurance provisions are summarized below. If you have any questions, contact AOTS.

1. Type of coverage and amount to be paid

1) Indemnity in the event of death
　 Insurance will be paid in the event of a trainee’s death within 180 days after an accident resulting in a fatal injury,
　 or in the event of death due to an illness contracted during the course of training. The insurance company will
　　 pay the entire sum to the trainee’s beneficiary as defined under the country’s probate laws of the trainee.
　 >> Amount to be paid: JPY 5 million

2) Insurance for disability resulting from an injury

　 Insurance will be paid in the event that a trainee is injured in an accident, as the result of which the trainee develops
　 a disability within 180 days of the accident.
>> Amount to be paid: 3% to 100% of JPY 5 million, depending upon the severity of the disability

3) Insurance to cover treatment costs and Rescue expenses

● Treatment costs

Treatment costs will be covered when a trainee must receive medical treatment as the result of an accident, or when
a trainee must receive medical treatment for an illness. Since funds are paid through AOTS directly to the medical
institution, the trainee is not required to make provisional payments for medical expenses.
● Rescue expenses
If during the training period, a trainee dies as the result of an injury or illness, is missing due to an accident, or is
hospitalized for three or more days, necessary rescue expenses (transportation, accommodation, etc.) will be paid
from the insurance benefit/settlement.
>> Amount to be paid for total of treatment costs and rescue expenses: Up to JPY 6 million
Note that certain types of expenses will be covered only in part.

4) Insurance to cover liability

　 When a trainee is legally liable to pay compensation for injuries caused to another person or damage to another
　 person’s property, the insurance will cover the amount of damage for which a trainee is liable. However, coverage
does not include accidents occurring during training activities.
>> Amount to be paid: Damage liability amount (up to JPY 10 million)

2. Submitting an insurance claim

　　AOTS will submit applications for insurance claims. Report any injury or illness as soon as possible to AOTS.

3. Special notes
　　Please note that the coverage excludes the following categories of events or conditions, which are further defined below:
1) Death, disability caused by an illness or injury, injury treatment costs, or rescue expenses involving any of the following:
　　 (1) Injury or illness predating entry into Japan
　　 (2) Injury or death resulting from fighting, suicide, or criminal behavior
　 　 However, in the event of suicide, rescue expenses will be covered.
　 　(3) Injury or death resulting from driving without a license or under the influence of alcohol
　 　(4) Injury or death resulting from brain disease or insanity
　　 (5) Pregnancy, delivery, premature delivery or a miscarriage and illness due to this, a surgical operation, and other
　 　 medical treatments.
　　 (6) Dental treatment, etc.
　 　 However, AOTS will pay for dental treatment costs for emergency treatment such as pain-killing, extraction, silver
　 　 filling, tooth crown, etc., based on separately established standards.
　　2) Liability in any of the following cases:
　　 (1) Accidents for which a trainee is liable that occur during training
　 　(2) Accidents for which a trainee is liable, involving articles entrusted to the trainee by another person
　　 (3) Automobile accidents for which a trainee is liable, etc.

Since the insurance does not cover every type of accident, injury, illness, or loss, please take appropriate precautions
JPO/IPR Training Program FY 2018 Part 5
to avoid accidents and damage to your health during the training period.

THE ASSOCIATION FOR OVERSEAS TECHNICAL COOPERATION AND SUSTAINABLE PARTNERSHIPS (AOTS)

Page 9
 JPO/IPR Training Program　FY 2018 Part 6

【Part 6】 About the Handling of Personal Information Concerning Applicants and Trainees

Your Name Course Name

Personal information of applicants and trainees acquired by the Association for Overseas Technical Cooperation and Sustainable
Partnerships (AOTS) from application documents concerning JPO/IPR training program shall be handled as follows. Please
carefully read the terms below and check the box at the bottom.

1. Manager in charge of personal information and the point of contact

Manager: General Manager, General Affairs & Planning Department, AOTS
Point of contact: General Affairs Group Tel : 81-3-3888-8211　　E-mail :

2. Purpose of use of personal information

The personal information provided will be used within the scope of use indicated below.

Provision to a Third
Documents Provided Purpose of Use
Party
Before Arrival to Japan
（１） JPO/IPR Training Application Form Screening of applicants’ qualifications Yes
A (Except Religious affiliation) Preparation of invitation documents Yes
Preparation of a name list for the courses of participation Yes
（１） JPO/IPR Training Application Form Consideration for life in Japan No
B (Religious affiliation)
（2） Copy of Passport Confirmation of applicants’ name and dates of birth, etc. Yes
Arrange flights to and from Japan and accommodation
（3） Medical Check Sheet Enrollment in and payment of travel insurance Yes
Health management after arrival to Japan
（4） Consent Form (for travel insurance) Purchase and payment of travel insurance Yes
（5） Reasons for Applying Understanding the current situation of applicants Yes
After Arrival to Japan
Delivery of various notices on AOTS and of questionnaires
(1) Registration Card after returning home. Notification of activities from an alumni Yes
society in each country.
(2) Questionnaire on Restriction on Meals Meal arrangement while the course is in session No
(3) Evaluation Sheet (if applicable) Improvement on future training courses No
(4) Copy of Passport Confirmation on VISA qualification and the valid term of VISA Yes

3. Provision to a Third Party

The personal information provided may be provided to a third party ("Third Party") for the following purposes using the
methods indicated below. Upon such provision, the handling of personal information will be supervised to ensure that the
personal information is handled appropriately by AOTS and the Third Party.

Items Purpose of Provision Method Third Party

Screening of qualification of applicants; preparation ・Paper
Name/date of birth/ Collaborating partners in
of invitation documents; preparation of a name list ・Data
nationality/affiliation/ the training, contract
Before arrival for trainees; purchase and payment of the
academic background/ companies, medical
to Japan traveler's insurance; health management after
career/photo/sex/ institutions, government-
arrival to Japan; understanding the current
health information affiliated agencies
conditions of applicants
・Paper Trainees, collaborating
Delivery of various notices on AOTS and of
partners in the training,
Name/sex/ questionnaires after returning home; notification of ・Data
After arrival contract companies,
address/place of activities from an alumni society in each country;
to Japan medical institutions,
employment/photo confirmation on the effects of training (if
government-affiliated
applicable); implementation report
agencies

4. Outsourcing
In principle, handling of personal information provided will not be outsourced.

5. Disclosure, correction, cessation of use, deletion, etc.

We will respond to requests for disclosure, correction, cessation of use, and deletion of personal information provided to us. In
this situation, please submit requests to the office shown in 1. above.

6. Completion of forms
Provision of information is voluntary. However, without consent, it is impossible to participate in certain courses, receive the
allowances of staying in Japan, or receive certain services after returning home.
 JPO/IPR Training Program　FY 2018 Part 6
Provision of information is voluntary. However, without consent, it is impossible to participate in certain courses, receive the
allowances of staying in Japan, or receive certain services after returning home.

Do you consent to the terms of our handling of personal information concerning applicants and trainees? Please tick
with an X mark in the relevant box. If you do not consent to the terms, your application will be excluded from our
screening.
　I consent 　I do not consent

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