Mexico Japan Exchange Program for the Strategic Global Partnership APPLICATION FORM

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APPLICATION FORM Please type in capital letters. Do not leave any space blank. Use N/A when applicable. 1. Title of the Training Program: 2. Applicants particulars AFFIX A RECENT PASSPORT-SIZE PHOTOGRAPH HERE Salutation Dr/Mr/Mrs/Ms/Others (please select accordingly) Family Name Given Name Nationality Date of birth Passport Passport Expiry Date Gender Marital status Dietary Religion Restrictions (if any) 3. Home State/Province City/Town Postal Postal Code Tel. No Mobile Primary Secondary 4. Office State/Province City/Town Postal Postal Code Tel. No Fax 5. Person to be notified in case of emergency Name Relationship Contact 6. Beneficiary of Travel Insurance Name Date of birth Relationship Contact 1

7. Employment History (starting with present position, i.e. in reverse chronological order) Organization Department Designation Nature of Job From To 8. Educational Record (starting with Higher Education, i.e. in reverse chronological order) Institution Degree obtained Major From To 9. English proficiency Excellent Good Fair Poor Listening Speaking Reading Writing Certificate examples TOEIC: 700 TOEFL PBT: 550 TOEFL IBT: 83 IELTS: 6 Other languages: Excellent Good Poor 10. Profile of Organization Name of Organization Type of Organization National Government Local Government Public Enterprise Private NGO University Other (specify) 11. Present position and current duties Department/Division Present position Date of employment by present Organization Date Month Year Date of assignment to the present position Outline of duties: describe your current duties Date Month Year 2

The mission of the Organization and the Department of Division Reason for applicant s selection The post which the applicant will be required to fill upon satisfactory completion of the training Relevance of the course to applicants job 12. Expectation of the applied training program Personal Goal: Describe what you intend to achieve in the applied training program. Relevant experience. Describe your previous vocational experiences which are highly relevant in the themes of the applied training program. of Interest: Describe your subject of particular interest with reference to the contents of the applied training program. 13. Previous Attendance Have you attended any courses sponsored under the Mexico Japan Exchange Program for the Strategic Global Partnership previously? If yes, please state the tittle and date of course(s). Yes/No Date (Year) Course tittle 13. Declaration (to be signed by the Nominee) I certify that the statements I made in this form are true and correct to the best of my knowledge. If accepted for the program, I agree: (a) not to bring or invite any member of my family, (b) to carry out such instructions and abide by such conditions as may be stipulated by both the nominating government and the Mexican Government regarding the program, (c) to follow the program, and abide by the rules of the institution or establishment that implements 3

the program, (d) to refrain from engaging in political activity or any form of employment for profit or gain, (e) to return to my home country at the end of the activities in Mexico on the designated flight schedule arranged by the Mexican Institutions, (f) to discontinue the program if the Mexican institution and the applying organization agree on any reason for such discontinuation and not to claim any cost or damage due to the said discontinuation. (g) to consent to waive exercise of my copyright holder s rights for documents or products that are produced during the course of the project, against duplication and/or translation, as long as they are used for the purposes of the program. (h) to observe Mexican laws and ordinances during my stay, if I violate Mexican laws and ordinances, (i) I will return the total amount or a part of the expenditure required for the training depending on the extent of the violation. (j) to approve the following privacy policy: Information Security Policy in relation to Personal Information Protection. a) Mexican Government authorities will properly and safely manage personal information collected through this application form in accordance with its privacy policy and the relevant laws of Mexico concerning protection of personal information and take protection measures to prevent divulgation, loss or damages of such personal information. b) Unless otherwise obtained approval from an applicant itself or there are valid reasons such as disclosure under laws and ordinances, etc. Print name Signature Date Day Month Year 4

MEDICAL HISTORY AND EXAMINATION 1. Present Status (a) Do you currently use any drugs for the treatment of a medical condition? (Give name & dosage.) ( ) No ( ) Yes >> Name of Medication ( ), Quantity ( ) (b) Are you pregnant? ( ) No ( ) Yes ( months ) (c) Are you allergic to any medication or food? ( ) No ( ) Yes >>> ( ) Medication ( ) Food ( ) Other: (d) Please indicate any needs arising from disabilities that might necessitate additional support or facilities. ( ) Note: Disability does not lead to exclusion of persons with disability from the program. However, upon the situation, you may be directly inquired by the JICA official in charge for a more detailed account of your condition. 2. Medical History (a) Have you had any significant or serious illness? (If hospitalized, give place & dates.) Past: ( ) No ( ) Yes>>Name of illness ( ), Place & dates ( ) Present: ( ) No ( ) Yes>>Present Condition ( ) (b) Have you ever been a patient in a mental hospital or been treated by a psychiatrist? Past: ( ) No ( ) Yes>>Name of illness ( ), Place & dates ( ) Present: ( ) No ( ) Yes>>Present Condition ( ) (c) High blood pressure Past: ( ) No ( ) Yes Present: ( ) No ( ) Yes>>Present Condition ( ) mm/hg to ( ) mm/hg (d) Diabetes (sugar in the urine) Past: ( ) No ( ) Yes Present: ( ) Yes>>Present Condition ( ) ( ) No Are you taking any medicine or insulin? ( ) No ( ) Yes (e) Past History: What illness(es) have you had previously? ( ) Stomach and ( ) Liver Disease ( ) Heart Disease ( ) Kidney Disease Intestinal Disorder ( ) Tuberculosis ( ) Asthma ( ) Thyroid Problem ( ) Infectious Disease >>> Specify name of illness ( ) ( ) Other >>> Specify ( ) (e ) Has this disease been cured? ( ) Yes ( ) No (Specify name of illness) Present Condition: ( ) 3. Other: Any restrictions on food and behavior due to health or religious reasons? I certify that I have read the above instructions and answered all questions truthfully and completely to the best of my knowledge. I understand and accept that medical conditions resulting from an undisclosed pre-existing condition may not be financially compensated by the Mexican Government and may result in termination of the program. Date: Signature: Print Name: 5

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