Curriculum Vitae for the Applicant for

International Youth Development Exchange Program (INDEX)

Please enter this excel form or type clearly in English

Country
Photograph

Leader / Participant □ Leader □ Participant - 4.5 cm X 3.5 cm

- Upper half of body
Name (Name to be written on (First) (Middle) (Family) - No hat
official address and certificate of - Plain background
completion) - Within the past six
months
Date of Birth （YYYY/MM/DD) YYYY/MM/DD Age

Nationality

Number

Name as shown
in passport
Passport Sex □ Male □ Female
Information
□ General □ Official □ Diplomatic
for Public Official if
using your official
Type passport to enter
Japan

Date of issue YYYY/MM/DD Date of expiry YYYY/MM/DD

Address
Contact
E-mail
Information
Home phone Mobile phone

□ Employee (Government) □ Employee (Private)

□ Employee (NGO/NPO) □ Self-employed
Occupation
□ Teacher □ Student
□ Other ( )

Name

Office or School Title E-mail

Phone FAX

Name Relationship

Emergency Address
Contact E-mail

Home phone Mobile phone

Native language
Language Other linguistic
ability (other
than English)

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 □ Buddhism □ Christian □ Other
Religion
□ Hinduism □ Islam （ ）

Please describe what motivated

you to apply to this program (200
words)

Please describe what issues you

are interested in related to the
theme (200 words)

For those who have an

experience of social activities
related to the themes for more
than 3 years, please describe
details of such activieies (200
words)

Experiences of participation in
international exchange programs
(Exchange countries, details)

Special skills

Matters of interest about Japan

□ Yes □ No
Experience of travel to Japan
（Date and purpose: ）
Are any of the following applicable to you?

□ Yes □ No

You have:
◆been sentenced to imprisonment for 1 year or more in any country.
◆been deported or removed from Japan or any country for overstaying your visa or
Criminal record, etc. violating any law or regulation.
(“Criminal record, etc.” shall be ◆been convicted and sentenced for a drug offence in any country in violation of law
filled by applicants from the concerning narcotics, marijuana, opium, stimulants or psychotropic substances.
countries of the visa exemption ◆engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
arrangement being set to enter persons, or in the provision of a place for prostitution, or any other activity directly
Japan.) connected to prostitution.
◆committed trafficking in persons or incited or aided another to commit such an offence.

NOTE
A foreign national who falls the Immigration Control and Refugee Recognition Act shall
be denied permission to land in Japan, in principle,
As a special application is required for persons falling under the above, the Cabinet
Office should be consulted in advance through the national government of you.
(The above notes are the same as those listed in a regular visa application.)

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 Personal Health Report
This form is to be used for program preparation. Please fill in all the questions below.
Q１. Do you have any disease or had in the past?
□ Yes □ No
*If YES, please discribe more details.
Disease Present condition

Q2. Do you take any medicines regularly?

□ Yes □ No
*If YES, please discribe more details.
Kind/name of medicine When do you take? How often do you take?

Q3. Do you have any food restrictions or allergy?

□ Yes Reason: □ Allergy → Please describe more details in Q6.
□ Religion
□ Vegetarian
□ Others （ ）
□ No

◇If YES, please check in the boxes of the items that you CANNOT eat or drink.
□ Non-halal food □ Eggs
□ Non-kosher food □ Milk
□ Meat □ Other dairy (cheese, yogurt etc.)
Specify: □ Peanuts
□ Pork □ Nuts
□ Chicken □ Gluten (wheat)
□ Beef □ Buckwheat (soba)
□ Other animal meat □ Alcohol
□ Meat extract □ Caffeine
□ Fish/Seafood □ Others （ ）
Specify:
□ Fish (cooked)
□ Raw fish
□ Shellfish (clams, oysters etc.)
□ Crabs
□ Shrimps
□ Fish/Seafood extract
□ Roe (fish eggs)

Q4. Do you have any allergy other than food?

□ Yes → Please describe more details in Q6.
Specify:
□ Cats □ Dust □ Pollen (hey fever)
□ Dogs □ Penicillin □ Others （ ）
□ No

Q5. Do you smoke?

□ Yes (Smoker)
□ No (Non-smoker)

Q6. Please describe more details of your allergy, if your answer is YES for Q3 and/or Q4.

Allergen Symptom Care to the symptom

Please describe any concerns for your health conditions during your stay in Japan if any.

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 CONSENT FORM
You need to agree on the following items to apply for the participation of the program.
Please check the box (☐ from 1 to 6) to show your agreement on the items.
□ 1) I meet the requirements of the qualification stipulated in guidelines for selection.
□ 2) I understand that the cases such as being considered as “inappropriate as a participating youth”
because of the absence in the program without proper reasons such as death or critical condition of
immediate family, and being unable to continue participating the program because of own illness will
be reasons for disqualification of participation and the certificate of the completion of the program will
not be granted.
□ 3) If I have faced any health concerns after applying for the position or during the program, I will
promptly report them to the Government of Japan. In the event of a health problem that disrupt my
participation in the program, I will also promptly report them to the Government of Japan and I
understand that those health problems would be a reason for disqualification of participation as
“inappropriate as a participating youth”.
□ 4) I understand that there may be occasions to take measures such as changing the schedule of or
canceling the program for various reasons.
□ 5) I agree on the following items on the handling of personal information
・The information you provided in the application form will be used for the selection and determination
of the participating youths.
・As for the selected participating youths, necessary information may be used for the execution of the
program. The information may be provided to other participating youths, contractor, governments of
participating countries, local governments and alumni associations of the program for the execution of
the program.
・This program will be recorded (video voice record, and photo shoot) by the Government of Japan
and the contractor.
・The collected information will be handled only for the stated purpose.

□ 6) I hereby certify that the above statement is true and correct.

Country: Name: Date:DD/MM/YYYY

 (Attachment 3)

Curriculum Vitae for the Applicant for

2018 International Youth Development Exchange Program
Please enter this excel form or type clearly in English

Country

Leader / Participant □ Leader □ Participant Photograph

- 4.5 cm X 3.5 cm
(as shown in passport) - Upper half of body
- No hat
- Plain background
- Within the past six
(First) (Middle) (Family) months
Name

Your name will be described as shown in passport in the program official documents. If you prefer

other description, specify: ( )

Sex □ Male □ Female

Date of Birth （YYYY/MM/DD) YYYY/MM/DD Age

Nationality

Number
Passport Type □ □ General □ Diplomatic
Information Official (for
Public Official if using your
official passport to enter
Japan)

Date of issue YYYY/MM/DD Date of expiry YYYY/MM/DD

Address

E-mail
Contact
Information
Home phone Mobile phone

FAX

□ Employee (Government) □ Employee (Private)

□ Employee (NGO/NPO) □ Self-employed
Occupation
□ Teacher □ Student
□ Other ( )

Name

Office or School Position E-mail

Phone FAX

Name Relationship

Address
Emergency
E-mail
Contact
Home phone Mobile phone

FAX

Mother tongue
Language

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Language Other linguistic
ability (other
than English)

□ Buddhism □ Hinduism □ Other

Religion
□ Christian □ Islam （ ）

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Involvement in youth activities
(Name of organizations, record of
youth activities, etc.)

Experiences of international
exchange programs
(Exchange countries, details)

Special skills

Matters of interest about Japan

□ Yes □ No
Experience of travel to Japan
（Date and purpose: ）
□ Yes □ No

You have:
◆been convicted of a crime or offence in any country.
Applicants from Republic of Chile, ◆been sentenced to imprisonment for 1 year or more in any country.
Dominican Republic, Republic of ◆been deported or removed from Japan or any country for overstaying your visa or violating
Estonia and Ireland only. any law or regulation.
◆been convicted and sentenced for a drug offence in any country in violation of law concerning
narcotics, marijuana, opium, stimulants or psychotropic substances.
◆engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
Criminal record, etc. persons, or in the provision of a place for prostitution, or any other activity directly connected
※ “Criminal record, etc.” shall be to prostitution.
filled by applicants from the ◆committed trafficking in persons or incited or aided another to commit such an offence.
countries of the visa exemption
arrangement being set to enter
Japan.
*Under the Immigration Control and Refugee Recognition Act, a person who may be applicable
to one of these items above cannot enter Japan in principle.
If applicable to any of these items above, please consult a person in charge of the matter of
your government as a special request may be necessary for an entrance.
(These items are the same as the ones appear in an ordinary visa application.)

The information that you provide may be used for the selection and determination of the invitees.
As for the actual invitees, necessary information may be used for 1) the execution of the program and 2) the establishment and
maintenance of the network of ex-participants. Further, these information may be provided for the other invitees and those who
are concerned with the program for the purpose of 1) and provide for the post-program activities organization (International Youth
Exchange Organization of Japan (IYEO)) for the purpose of 2) respectively
All data is securely held in accordance with ‘Act for Protection of Personal Data Held by Administrative Organs.’

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