Reg.No.

Entry Form for JENESYS 2.0 Programme

(Country: MALAYSIA　　　　　 　　　　 )

1. Personal Information * Please fill in the form in BLOCK LETTERS.

Full Name (Exactly the same as your passport) (in English)
Photo Name
GUBINATH BALASUBRAMANIAM
(taken within 3
months) Given name (English) Family Name (English) Middle Name (English) (if any)

Please GUBINATH BALASUBRAMANIAM

write your name
on the back of Full Name (in Mother language)
your photo.
GUBINATH A/L BALASUBRAMANIAM

Date of Birth (Day) (Month) (Year)

Age (as of the
(as shown on your starting day of 23
passport) 18 MEI 1991 the programme)

Nationality MALAYSIA Sex ✘ Male Female

Buddhist Christian ( Roman Catholic

Protestant Other ) 　
Religion
✘ Hindu Muslim Others (　　　　　　　 　　　　 )

Mother Tongue TAMIL Marital Status ✘ Single Married

Number Type of Passport

A34434078 　　 ✘ Private Diplomat Official
Passport**
Date of Issue Date of Expiry
(Day) (Month) (Year) (Day) (Month) (Year)

21 JAN 2015 21 JAN 2020

Address

NO 256, JALAN SELASIH 3, TAMAN SELASIH, 09000 KULIM, KEDAH, MALAYSIA

Current Address

Tel: +604-4959722 Fax:

Mobile: +6014-9448473 E-mail: [email protected]
Full Name Relationship

MUTUKUMARAN BALASUBRAMANIAM BROTHER

Contact Person Address

in Emergency
*It shall be your parent. NO 256, JALAN SELASIH 3, TAMAN SELASIH, 09000 KULIM, KEDAH, MALAYSIA
*If you live with him/her,
please leave address
blank. Tel: +604-4959722 Fax:
Mobile: +6016-4885436 [email protected]
Profession/Occupation: ENGINEER
Full Name Relationship
*If you do not have
phone at your current
address, please write
contact person and
number.
Revised on 20/11/2013
 *If you do not have
phone at your current
address, please write
contact person and Phone Number: E-mail:
number.

**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 ✘ O AB UNKNOWN

✘ Good

□Having Chronic disease

　Please specify:
□chronic lung disease (asthma, chronic obstructive lung disease etc.)
□immunodeficiency state (T cell immunodeficiency etc.)　
Health Condition □chronic heart disease (congenital heart disease, coronary artery disease etc.)
□metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis
□infectious diseases (Specified: )
□others ( )

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
□Taking medicines regularlly ( Specified： 　　　　　　　　 　　　　　 )　　　
Pregnancy *Pregnant women cannot participate in JENESYS 2.0 Programme
□Yes 　□No owing to maternal and child health reason.
*for women

□None
✘
Food Allergies
(which may cause □Shrimp □Crab □Shellfish □Fish □Egg
allergic reaction)
□Others ( )
□None
Food Restriction □Pork ✘□Beef □Chicken □Mutton/Lamb　 □Shrimp　 □Crab □Shellfish
(for religion or
custom reason) □Fish □Egg □Others ( )
*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

Dietary □None
✘

Requirements □Vegitarian □Vegan □Halal □Others ( )

Other Allergies and □None

✘

Restriction □Dogs □Cats □House dust □Others ( 　　　　　　　　 　　　　 )

3. Academic Details
Name of School / University Location (city,province)

UNIVERSITI MALAYSIA PERLIS KANGAR, PERLIS

Tel: +604-9778008 Fax: +604-9798703

Information of your Field of study (for DEGREE IN ELECTRONIC ENGINEERING

School/University university student only)
Grade/school year (for
student)
as of the day of the flight to
3rd YEAR
Japan
* I confirm that I am a student (possess student ID) ✘ Yes No
Profession/Occupation:
For Supervisor only
Title
English Proficiency
certificated score (if any, e.g. MUET
TOEFL)
Level of English Level of Japanese
Speaking :✘ Good Fair Poor Speaking : Good Fair ✘ Poor
Language
Revised on 20/11/2013
 ✘ ✘

Language Writing :✘ Good Fair Poor Writing : Good Fair ✘ Poor

Reading : ✘ Good Fair Poor Reading : Good Fair ✘ Poor
Japanese Year or Month
Other
JAPANESE learning
Language experience 6 MONTHS

Revised on 20/11/2013
4. Personal Activities
Activities Period of Involvement

Sports/Clubs TAEKWON-DO 12 YEARS

Hobbies READING/ DRAWING/ SKETCHING

Academic Awards
DEAN LISTED (DIPLOMA IN ELECTRONIC ENGINEERING)
(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 befor 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)

Revised on 20/11/2013
Signature: Date: 20 / 01 / 2015

Revised on 20/11/2013
ANNEX

Revised on 20/11/2013
Revised on 20/11/2013
 Reg.No.

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 Name
JAMES JOHN SMITH
(taken within 3
months) Given name (English) Family Name (English) Middle Name (English) (if any)

Please JAMES SMITH JOHN

write your name
on the back of Full Name (in Mother language)
your photo.
JAMES JOHN SMITH

Date of Birth (Day) (Month) (Year)

Age (as of the
(as shown on your starting day of 20
passport) 01 January 1994 the programme)

Nationality AUSTRALIA Sex ✘ Male Female

Buddhist ✘ Christian ( Roman Catholic

Protestant Other ) 　
Religion (　　　　　　　 　　　　 )
Hindu Muslim Others

Mother Tongue ENGLISH Marital Status ✘ Single Married

Number Type of Passport

L1234567 　　 ✘ Private Diplomat Official
Passport**
Date of Issue Date of Expiry
(Day) (Month) (Year) (Day) (Month) (Year)

01 April 2014 01 April 2024

Address

123 JENESYS ROAD, SYDNEY, NSW 4567, AUSTRALIA

Current Address

Tel: +61-1-234-567 Fax: +61-1-234-567

Mobile: +61-7-654-321 E-mail: [email protected]
Full Name Relationship

PETER SMITH FATHER

Contact Person Address

in Emergency
*It shall be your parent. 123 JENESYS ROAD, SYDNEY, NSW 4567, AUSTRALIA
*If you live with him/her,
please leave address
blank. Tel: +61-1-234-567 Fax: +61-1-234-567
Mobile: +61-7-987-654 E-mail: [email protected]
Profession/Occupation:
Full Name Relationship
*If you do not have
phone at your current
address, please write
contact person and
number.
Revised on 20/11/2013
 *If you do not have
phone at your current
address, please write
contact person and Phone Number: E-mail:
number.

**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 O AB UNKNOWN

✘ Good

□Having Chronic disease

　Please specify:
□chronic lung disease (asthma, chronic obstructive lung disease etc.)
□immunodeficiency state (T cell immunodeficiency etc.)　
Health Condition □chronic heart disease (congenital heart disease, coronary artery disease etc.)
□metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis
□infectious diseases (Specified: )
□others ( )

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
□Taking medicines regularlly ( Specified： 　　　　　　　　 　　　　　 )　　　
*Pregnant women cannot participate in JENESYS 2.0 Programme
Pregnancy □Yes 　□No
✘
owing to maternal and child health reason.

□None
Food Allergies
(which may cause □Shrimp
✘ □Crab □Shellfish □Fish □Egg
allergic reaction)
□Others ( )
□None
✘

Food Restriction □Pork □Beef □Chicken □Mutton/Lamb　 □Shrimp　 □Crab □Shellfish

(for religion or
custom reason) □Fish □Egg □Others ( )
*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

Dietary □None
✘

Requirements □Vegitarian □Vegan □Halal □Others ( )

Other Allergies and □None

Restriction □Dogs ✘ □Cats □House dust □Others ( 　　　　　　　　 　　　　 )

3. Academic Details
Name of School / University Location (city,province)

JENESYS2.0 UNIVERSITY SYDNEY

Tel: +61-3-111-222 Fax: +61-3-333-444

Information of your Field of study (for COOL JAPAN

School/University university student only)
Grade/school year (for
student)
as of the day of the flight to
SOPHOMORE
Japan
* I confirm that I am a student (possess student ID)
✘ Yes No
Profession/Occupation:
For Supervisor only
Title
English Proficiency
certificated score (if any, e.g. NATIVE
TOEFL)
Level of English Level of Japanese
Speaking :✘ Good Fair Poor Speaking : Good ✘ Fair Poor
Language
Revised on 20/11/2013
 ✘ ✘

Language Writing :✘ Good Fair Poor Writing : Good Fair✘ Poor

Reading : ✘ Good Fair Poor Reading : Good Fair✘ Poor
Japanese Year or Month
Other
JAPANESE learning
Language experience 1 YEAR

Revised on 20/11/2013
4. Personal Activities
Activities Period of Involvement

Sports/Clubs FOOTBALL 6 YEARS

Hobbies READING / WATCHING MOVIE

Academic Awards
DEAN'S LIST LETTER
(if any)

5. Essay *Please answer the two questions in 250 - 300 words. You may attach additional pages as needed.
This is a sample, this is a sample, this is a sample, this is a sample.

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 befor ✘ Yes No If Yes, When? year 2000

If Yes, what was the purpose of

Family Trip
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)

Revised on 20/11/2013
 Signature: Date: / /

ANNEX

Revised on 20/11/2013
Revised on 20/11/2013