Application form

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CONFIDENTIAL

Annex 2. Application Form

*Please sign all the pages in the bottom right-hand corner.

* HANDWRITTEN FORMS will not be accepted

* Please provide information in English

Reg. No. 　　　

Japanese Initiative for the future of Syrian Refugees (JISR) for 2019

APPLICATION FORM

1. Field of Study and University 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

Please provide the following information, referring to the Application Guidelines as necessary. Every applicant must specify the area, research field, graduate school code, name of the selected university and graduate school and the supervisor’s name in the table below, referring to Annex 4 “List of Japanese Universities and Research Fields.” Please fill in your first, second, and third priority universities if any.

Priority	Area of study Engineering, Agriculture, ICT, Business Administration, Social Science, Japanese Language and Culture	Research Field	Graduate School Code	Name of selected University and Graduate School	Academic Supervisor of your choice
Example	Engineering	Civil Engineering materials	1	JISR University Graduate School of Engineering	Professor Taro Yamada
1
2
3

2. Personal Information　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

Attach the applicant’s photograph (taken within the last three months) here

Size: 4x3cm

(Attach to the documents to be submitted.)
(1) Program Title

Japanese Initiative for the future of Syrian Refugees (JISR)

(2) Number　(NO need to fill in, JICA will inform after selection procedures)

(3) Information about the applicant

1) Name of Applicant (as shown in passport or other official identification card, if any)

Family Name

First Name

2) Nationality (as shown in passport or other official ID card)				5) Date of Birth (please write out the month in English, as in “April”)
3) Sex	( ) Male	( ) Female		Date	Month		Year	Age
4) Religion
6) Marital Status	( ) Single		( ) Married			( ) Engaged
7) Place of birth			8) Month and year when Nominee started to reside in host country(Month/year)			( / )

9) Passport/Visa

Passport possession	( ) Yes	( ) No	Expiry date of passport	Date	Month	Year
UNHCR Registration Card or Asylum Seeker Certificate (AC)	(　) Yes	(　) No	Expiry date of passport

10) UNHCR Registration information:

－

UNHCR Case Number/Barcode

－

UNHCR Individual Registration Number
Country of asylum/current residence: Jordan / Lebanon (Please choose one)
11) Name of Applicant’s parents

	Relationship to the Applicant	Name	Place of birth	Date of birth (Date/Month/Year)
1	father
2	mother

13) Contact Information

Home	Address:
	TEL:	Mobile (Cell Phone):
	FAX:	E-mail:
Contact person in case of emergency	Name: Relationship to you:
	Address:
	TEL:	Mobile (Cell Phone):
	FAX:	E-mail:

3. Educational Background　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

Level	Name of School / Department	Location (City and Country)	Number of years of schooling you have attended	From /To (Month/Year)	Degree
Example	* University Faculty of *	Damascus, Syria	4 Years	9/2004 to 6/2008 Month/Year Month/Year	Bachelor of ***
Primary Education				/ to / Month/Year Month/Year
Lower Secondary Education				/ to / Month/Year Month/Year
Upper Secondary Education				/ to / Month/Year Month/Year
Higher Education (University level)				/ to / Month/Year Month/Year
Other Higher Education (except training)				/ to / Month/Year Month/Year
Other Higher Education (except training)				/ to / Month/Year Month/Year
Total Years of Education: __________ year(s) ________ month(s)

Please describe in English the outlines of your studies at the higher education (university level education or other higher education. If you completed an undergraduate thesis, please briefly explain the outline of your argument. Please describe in 400-500 words.

Mother Tongue: ____________________

Language Proficiency

1) State your level of English proficiency
Listening	( ) Excellent	( ) Good	( ) Fair	( ) Poor
Speaking	( ) Excellent	( ) Good	( ) Fair	( ) Poor
Reading	( ) Excellent	( ) Good	( ) Fair	( ) Poor
Writing	( ) Excellent	( ) Good	( ) Fair	( ) Poor
Certificate (Examples: TOEFL, IELTS)
2) Japanese	( ) Excellent	( ) Good	( ) Fair	( ) Poor
3) Other languages ( )	( ) Excellent	( ) Good	( ) Fair	( ) Poor

Excellent: Refined fluency skills and topic-controlled discussions, debates & presentations. Formulates strategies to deal with various essay types, including narrative, comparison, cause-effect & argumentative essays.
Good: Conversational accuracy & fluency in a wide range of situations: discussions, short presentations & interviews. Compound-complex sentences. Extended essay formation.
Fair: Broader range of language related to expressing opinions, giving advice, making suggestions. Limited compound and complex sentences & expanded paragraph formation.
Poor: Simple conversation level, such as self-introduction, brief question & answer using the present and past tenses.

Have you ever studied abroad?

[ ] Yes Name of the Academic institution/Scholarship (if any):
Country where you studied:

Duration: From (month/year) to (month/year)

[ ] No

Are you currently applying for any scholarship(s), other than the Japanese Initiative for the future of Syrian Refugees (JISR)?

[ ] Yes Name of the Scholarship(s):
[ ] No

Have you ever participated in any training course in your country or abroad including those offered by JICA?

[ ] Yes Name of the course:
Country you visited:

Name of the institution or agency:

Duration: From (month/year) to (month/year)

[ ] No

4. Work Experience　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

Information about Organization and Position of your current or most recent work

Type of Organization

( ) A.

National Government

( ) B.

Local Government

( ) C.

Public/Private Enterprise

( ) D.

NGO/Private (Non-profit)

( ) E.

University

( ) F.

Other ( )

Organization

Department / Division

Position

Date of employment by the organization

Date

Month

Year

(if applicable)

Date of resignation

Date

Month

Year

Contact information for the organization

Address:

TEL:

Mobile phone (Cell Phone):

FAX:

E-mail:

2）Please describe in English your responsibilities and achievements in your most recent or previous employment. Be sure to sign each page. If you do not have work experience, please write “N/A.”

3) Information about work experience

Please provide information about your work experience, starting with your most recent employment. Full-time jobs, part-time jobs and jobs before graduation from university can be included.

Organization

Department

Position

Period of Employment

From /To

(Month/Year)

Full-time

or

Part-time

**

Type

Ex.

ABC Co., Ltd.

Department

Head

5 years

5 months

7/2008 to 12/2013

Month/Year Month/Year

Full

A

/ 　to /
Month/Year Month/Year

/ 　to /
Month/Year Month/Year

/ 　to /
Month/Year Month/Year

/ 　to /
Month/Year Month/Year

**For the type of organization, please choose from the following:

A. National Government, B. Local Government, C. Public/Private Enterprise, D. NGO/Private (Non-profit),

E. University, F. Other

Total years of full-time job experience: ________ year(s) _______ month(s)

　　Total years of part-time job experience: ________ year(s) _______ month(s)
5. Plan after returning to Syria

Regarding your chosen field of study shown on page 1, please describe your idea/ plan to utilize your knowledge, skills and experience that you will acquire in Japan after returning to Syria in the future when the country is sufficiently safe. Please describe in English in 400-500 words.

Please be reminded of the purpose of the Japanese Initiative for the future of Syrian Refugees (JISR), which expects Participants to contribute to the reconstruction and peacebuilding of Syria in the future, as well as strengthen the mutual friendship between Syria and Japan.

Be sure to sign each page.

6. Research Plan　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

To confirm the field of your research, please write down the same Research Field as in section “1. Field of Study and University” on the application form.

Research Field

On separates sheets of A4 sized paper, write a brief research plan of your proposed Master’s thesis using more than 700 words (maximum 3 pages) in English. During the selection process, this research plan will be used by faculty members of the relevant Japanese university to evaluate your academic ability and motivation. Be sure to sign each page.

(3) Below is an example of the structure of a research plan. While it is not essential to use this structure, it is strongly recommended. The ideal research proposal contains the following items. The pattern varies according to the particular subject, although the outline remains more or less the same.

RECOMMENDED TEMPLATE FOR YOUR RESEARCH PLAN

TITLE of your research plan
INTRODUCTION (1 paragraph):

State clearly what your research interests are. You need to include the following:

Background information regarding the selected topic and your involvement (e.g. what is the main reason that you chose the topic, your relevant working experience, etc.)
The main objective of your study

METHODOLOGY (approximately 3 paragraphs):

Provide specific information to support your ideas. Explain what you are going to study and how the research will be conducted. You need to include the following:

・　Brief explanation for your analysis of this topic.

・　Brief explanation for your research methodology.

Without digressing from the topic, explain in brief what you want to learn at the Japanese university you chose.

(d) CONCLUSION (1 paragraph):

Stress the most important point(s) of your research plan, and your future work. You need to include the following:

・　The skills you wish to obtain at a Japanese university.

・　How you intend to utilize your research contribute to Syria’s reconstruction and peacebuilding after returning to Syria.

* IMPORTANT *

It must be demonstrated that your academic background and job experience are sufficient to engage in and complete a Master’s course in Japan. In this regard, it is essential that you select a research theme which is relevant to your plan.
You must have a good understanding of the Master’s courses offered by the Japanese university of your choice. The description you provide in the research plan will be used to evaluate whether the course can support your research.

For more information on research plans and academic writing, you can find many helpful websites on line. The following website is an example.

http://www.buzzle.com/articles/how-to-write-a-research-proposal.html

(Title of your research plan)

(Content of your research plan)

PLEASE WRITE ON SEPARATE SHEETS OF PAPER

7. Medical History　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

(1) Present Medical Status

(a) Do you currently use any medicine or have regular medical check-ups by a physician for your illness?

[ ] No

[ ] Yes: Name of illness ( ) Name of medicine ( )

If yes, please attach your doctor's letter (preferably, written in English) that describes the current status of your illness and agreement to join the program.

(b) Are you pregnant?

[ ] No

[ ] Yes: Months of pregnancy ( months)

(c) Are you allergic to any medication or food?

[ ] No

[ ] Yes: What are you allergic to? ( )

(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 being notified of the situation, a JICA official in charge may contact you directly for a more detailed account of your condition.

(2) Past Medical History

(a) Have you had any significant or serious illness?

[ ] No

[ ] Yes: Please specify ( )

(b) Have you ever been a patient in a mental clinic or been treated by a psychiatrist?

[ ] No

[ ] Yes: Please specify ( )

(3) Other Medical Problems

If you have any medical problems that are not described above, please indicate below.

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 JICA and may result in termination of the program.

Date / /	Print Name
	Signature

8. Information about Family to be brought to Japan　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

	Name	Sex	Relation	Age	Date of birth (Date/Month/Year)	Passport possession	Please indicate when you want to bring them
1						( ) Yes ( ) No	( ) You will bring them with you when you come to Japan. ( ) You will not bring them with you when you come to Japan. You will invite him or her at least [　] months after your arrival.
1	Reason to bring him/her (e.g. He/She will have difficulty maintaining a livelihood without my support)
2						( ) Yes ( ) No	( ) You will bring them with you when you come to Japan. ( ) You will not bring them with you when you come to Japan. You will invite him or her at least [　] months after your arrival.
2	Reason to bring him/her (e.g. He/She will have difficulty maintaining a livelihood without my support)
3						( ) Yes ( ) No	( ) You will bring them with you when you come to Japan. ( ) You will not bring them with you when you come to Japan. You will invite him or her at least [　] months after your arrival.
3	Reason to bring him/her (e.g. He/She will have difficulty maintaining a livelihood without my support)

If you want to bring more family members, please add an extra row.
* IMPORTANT *

Participants can invite/bring ONLY a spouse and children to Japan who are eligible to be granted “Dependent” resident status in accordance with the Immigration Control and Refugee Recognition Act of Japan.
In principle, JICA recommends that Participants invite their family to Japan at least six months after the time of their arrival, since it will take approximately three months to complete administrative registration, house-renting, course registration at the university and so on. In addition, Participants need to familiarize themselves with Japanese life and obtain information relevant to living with family (such as public and local support systems for foreigners, medical and education services, etc.).

However, JISR Participants arriving in Japan together with their family will also be accepted considering their status as refugees, if the necessary documents have been prepared (visa, exit permit, etc.).

JICA/JDS/JAR will assist the family of a Participant with housing, entering children in school and counselling on life if necessary. Family members can take part in the Japanese Language Training Program held during the program together with the Participants.
JICA will provide the following expenses for the family of a Participant

・Airfare to Japan

・Family allowance (Spouse：13,000 yen/month、Child：6,500 yen/month)

・Spouse can work only after obtaining a permission to work (Shikakugai-katsudokyoka) from the immigration office within the scope of the law.
9. Declaration　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
I, (print your full name) ______________________________________________,

declare that I apply for the Japanese Initiative for the future of Syrian Refugees (JISR) with a full understanding of the “General Information for All Applicants on the Japanese Initiative for the future of Syrian Refugees (JISR)” (hereinafter referred to as the “Guidelines”), especially the articles stipulated below:

all the information answered and provided on this application form by me is true and accurate to the best of my knowledge and ability. My application will be cancelled if any information is proven to be false.
an application form which is incomplete or missing any necessary document(s) will be deemed ineligible and not considered.
the selection procedure and results rest entirely with JICA as the secretariat of the Japanese Initiative for the future of Syrian Refugees (JISR). No inquiries or objections by applicants regarding the results of the selection process will be considered.
if any act of dishonesty is found other than those mentioned above in the application and selection, I am to lodge no complaint about cancellation of the application.
information will be shared between JICA and UNHCR for the sole purpose of implementing the Japanese Initiative for the future of Syrian Refugees (JISR) and with other scholarship providers for the sole purpose of improving access to appropriate scholarship communities.

Furthermore, if I am accepted for the Japanese Initiative for the future of Syrian Refugees (JISR), I agree

to carry out such instructions and abide by such conditions as may be stipulated by the Japanese Government regarding the program,
to follow the program, and abide by the rules of the institution or establishment that implements the program,
to refrain from engaging in political activity or any form of employment for profit or gain while engaging in Master course.
to discontinue the program if JICA identifies any reason for such discontinuation and not to claim any cost or damage due to the said discontinuation,
to consent to waive my copyright holder’s rights for documents or products that are produced during the project against duplication and/or translation by JICA, as long as they are used for the purposes of the program,
to approve the privacy policy and the copyright policy described below:

Scope of Use

Any information used for identifying individuals that is acquired by JICA will be stored, used or analyzed only within the scope of JICA activities. JICA reserves the right to use such identifying information and other materials in accordance with the provisions of this privacy policy.

Limitations on Use and Provision

JICA shall never intentionally provide information that can be used to identify individuals to any third party, with the following three exceptions:

In cases of legally mandated disclosure requests;
In cases where the provider of information grants permission for its disclosure to a third party;
In cases where JICA commissions a party to process the information collected;　the information provided will be within the scope of the commissioned tasks.

Security Notice

JICA takes necessary measures to prevent leakage, loss, or destruction of acquired information, and to otherwise properly manage such information

JICA will properly and safely manage personal information collected through this application form in accordance with JICA’s privacy policy and the relevant laws of Japan concerning protection of personal information, and will take protective measures to prevent divulgation, loss or damages of such personal information.
Unless approval is otherwise obtained from an applicant him/herself, or there are valid reasons such as disclosure under laws and ordinances, etc., and except (a) - (c) below, JICA will neither provide nor disclose personal information to any third party. JICA will use personal information provided only for the purposes described in (a) – (c) below, and will not use personal information for any purpose other than described in (a) – (c) below without prior approval of an applicant him/herself.

To provide the Japanese Initiative for the future of Syrian Refugees (JISR) to Participants from Syria.
To provide the Japanese Initiative for the future of Syrian Refugees (JISR) to Participants from Syria under Citizens’ Cooperation Activities.
In addition to (a) and (b) above, if the government of Japan or JICA determines it necessary in the course of technical cooperation.

Participants of the Japanese Initiative for the future of Syrian Refugees (JISR) are requested to comply with the following copyright policy;

Article 1. Compliance matters with participants’ drafting of documents (various reports, action plans, etc.) and presentations (report meetings, lectures, speeches, etc.)

Any contents of documents and presentations shall be created by Participants themselves in principle.
Comply with the following matters, if you have to use over the specified limit of a third person’s work (reproduction, photograph, illustration, map, figure, etc.) that is protected under laws or regulations in your country, or copyright-related multinational agreements or the like:

Obtain a license to use the work on your own responsibility. In this case, the scope of the license shall meet the provisions of Article 2.
Secure evidential material that proves the grants of the license and specifies the scope of the license.
Consult with the third party and complete the payment procedure on your own responsibility regarding negotiations with a third person for consideration to be granted a license and the procedure for paying for the consideration.

Article 2. Details of use of works used for the Japanese Initiative for the future of Syrian Refugees (JISR)

The copyright on a work that a participant prepares for the Japanese Initiative for the future of Syrian Refugees (JISR) shall belong to the participant. The copyright on the parts where a third party’s work is used shall belong to the third party.
When using texts, supplementary educational materials and other materials distributed for the Japanese Initiative for the future of Syrian Refugees (JISR) courses, participants shall comply with the purposes and scopes approved by each copyright holder.

to observe Japanese laws and ordinances during my stay, if I violate Japanese laws and ordinances, I will return the total amount or a part of the expenditure required for the Japanese Initiative for the future of Syrian Refugees (JISR), depending on the extent of the violation,
to understand that JICA does not assure issuance of a Japan entry visa even after JICA decides to accept me. I understand that the Embassy of Japan will decide according to necessary formalities upon the submission of a visa application from each participant,
that I am required to contribute to the development of Syria’s relationship with Japan after completing the Master’s course and internship in Japan,
that the program can provide job-search support in Japan if necessary, but does not guarantee employment in Japan upon completion of the program,
that my personal information on the application form, provided to JICA, will be used for the purpose of implementing the program, and that the information will also be supplied to the relevant university and companies.

Signature: ______________________________

(*Please sign at the bottom of all the pages including this page)

Date: (day)_____/(month)_____/(year)_______

　　　　Name of Applicant:

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