JENESYS 2016: Japan East-Asia Network of Exchange

for Students and Youths

* Please fill in the form in BLOCK LETTERS.

2 inches
Full Name (Exactly the same as your passport )
ATTACH PHOTO HERE

Middle Name (if any)

2 inches

taken within 3 months.

Width:Heigth 2x2 inches OR
51x51 mm

Date of Birth

Gender M

Day/Month/Year

Please write your name on the back

of your photo.

Are you part of Kizuna/JENESYS 2.0/JENESYS 2015 Alumni?

Country of
Citizenship

Federated
States of
Micronesia

Cook Islands

No

Kiribati

Marshall Is

Nauru

Solomon Is

Tonga

Tuvalu

Fiji

Kiribati

Marshall Is

Nauru

Samoa

Solomon Is

Tonga

Tuvalu

Fiji
Samoa

PNG

Palau

Yes

Niue

Vanuatu
Country
Currently
Residing and
Studying in

Niue

Federated
States of
Micronesia

Cook Islands
Palau

PNG

Vanuatu

Do you have a valid passport?

Passport

Yes

No

Please attach a copy of the biodata page of your passport.

Passport Number

Date of Expiry

Address

Fax:

Full Name

Relationship

Current

Fax:

Emergency

Have you traveled outside your country before?

Indicate your preferred month of travel

Yes

No

If so, where?

First Choice:

Oct.

Nov.

January

February

Second Choice:

Oct.

Nov.

January

February

Third Choice:

Oct.

Nov.

January

February
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If you are not a USP student, please fill in the name of your University or College. Please provide your GPA :
Are you studying Full Time of Part Time?
Information
of University/
College

Full Time

Part Time
Undergraduate

Are you enrolled as Undergraduate or Postgraduate student?

Postgraduate

Programme you are currently enrolled in

Ple Please
What year are you in at your University or College ?
Are you sponsored by any scholarship?

Yes

No

If so, name the sponsor?

List contact details for two referees Referee 1:Name, Address Phone contact

Tuberculosis

Mental Illness

Blood disorder

Pregnancy

Cancer

Current
Medical
Conditions

Referee 2: Name, Address Phone contact

Respiratory Disease (requires hospital admission or oxygen

therapy)

Heart disease
Hepatitis B or c and/or liver disease
Kidney disease, including dialysis

Others (including Allergies)

Other Medical Conditions

Specify

Other Medical Conditions

Has disclosed with the USP Disability Resource Centre

Note: You will need to submit a medical certificate, which can be obtained from your General Practitioner (GP). View sample here. (& pg. 4)
Your answer will not exclude you from being selected
Dietary
Requirements

None

Food Allergies

Vegetarian
None
Other

Pork

Non-Vegetarian
Beef

Chicken

Gluten Free

Halal

Vegan

Vegan
Seafood

Specify

Please answer this question in no more than 500 words. You may attach additional pages as needed.

How will your

participation
in the JENESYS
2016 Project
contribute to
your
current/future
career goals?
Please support
your essay
with examples.

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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 Use of Personal Information
I agree that my personal information in the Application Form provided to the University of the South Pacific will be used only
for the purpose of the operation of JENESYS 2016: Japan-East Asia Network of Exchange for Students and Youths.
Signature:

Date:

DD/MM/YYYY

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1234 CLINIC
MEDICAL CLEARANCE CERTIFICATE: FITNESS TO TRAVEL

TO WHOM IT MAY CONCERN

This is to certify that on this day, 9th November 2015
I have examined
Ms Abcd
And found him/her to be medically fit to travel via air, sea and land as well.
Yours sincerely,
-------------------------------Dr Efgh

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