ࡱ>  #c RJbjbjCjW\W\``,t9_LLLLLUDUDUD^^^^^^^$/acT6^UDqBUDUDUD6^LL%'^FFFUD:LL^FUD^FF[]L?D[] _09_[9dE9d4]9d]|UDUDFUDUDUDUDUD6^6^FUDUDUD9_UDUDUDUD9dUDUDUDUDUDUDUDUDUD`N : NOT FOR SALE Please carefully read the Application Guidance before completing this form. Type or handwrite clearly, and do not exceed the space provided for each section. Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. Deadline is August 8, 2017 !! (FOR OFFICE USE ONLY: Registration Number ) The 20th Duskin Leadership Training in Japan A Program for Persons with Disabilities in Asia and the Pacific (2018) 1. NameFirst (given) name(s) Middle name Second (family) name In your native language: / / In English alphabet: / / 2. Sex3. Date of BirthMale & Female UnspecifiedYear Month Day 19 / / Age: (as of August 8, 2017)4. Contact details& Home & Office & Other (please specify : ) Postal address: Country: Telephone: Fax: Mobile phone : Email: 5. Type of disabilityPhysical & Visual & Hearing & Intellectual & Mental Other (please specify : )6. Nationality Attach your photo here A photo must show your face and entire body. It must have been taken in the past 3 months. If you are applying by post, please write your full name on the back of the photo. If you are applying by email, please send your photo as a separate attachment. 7. Native language (mother tongue) 8. Religion 9. Marital status& Single & Married Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. 10. What do you do? & I am a student & I work & Other (please specify : ) If you are a student, please provide details of your institution: Name of your School/College/Institution : Address : Your school Year/Grade:Your major:When do you expect to graduate? If you have employment or any other kinds of work, please provide details below. Your organization typeNGO & Public administration/government Private firm/institution & Other type of institution Self-employed & Family-run business Freelance & Other (details : )Your statusPaid staff & Unpaid staff/Volunteer Intern/Trainee & Other (details : ) Name of Your Employer (Organization/Company) :  Address : Telephone:Fax:Website:Email: Describe specialty of your organization and its main business :  Describe your job details including your present title :  Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. 11. Do you belong to any organization of/for persons with disabilities?No, I don t belong to any organization. % Yes, I belong to the following organization.Name of the organization :Address :Telephone:Website:Email:Its purpose and activities:How are you affiliated with this organization? (tick an appropriate box)Staff & Member & Volunteer Service user & Other Describe your involvement: 12. EducationA.University/ School Give the name of the institution from which you graduated, your degree/major and completion date. Please exclude information that you have already mentioned in Section 10.NameCity/CountryAttended From (Month/Year)Attended To (Month/Year)Degree, Certificate or DiplomaB.Training/Seminar List training courses and seminars etc. that you have attended and qualifications that you hold.NameCity/CountryFrom (Month/Year)To (Month/Year)Certificates obtained13. Work ExperiencePlease exclude information that you have already mentioned in Section 10.Name of employer/ organizationDescription of organizationFrom (Month/Year)To (Month/Year)Title, duties and responsibilities Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. 14. Reason for applying : Why do you want to participate in this training program? 15. Your training plan : What do you want to learn in Japan? 16. Your future plan : What will you do after training?  Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. 17. Your disability What is the name of your disability? Please provide details about your disability including medical records. 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Do you have a dietary, medical or any other restriction in your daily life due to your religion or health condition?  Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. 19. Describe your personal history. 20. What are your hobbies and interests? 21. Have you traveled abroad before? Give details of any travel experience abroad (e.g., study, training and holidays), including its destination, duration and purpose. 22. How did you learn about this program and where did you get this application form?  Note: Please type or handwrite clearly and tick appropriate boxes that should appear as &. 23. Your language skills  Circle a number that indicates your level on each scale bar. ENGLISH Speaking : NoneBasic communication Everyday conversation Business levelNative level12 3 45Listening: NoneBasic communication Everyday conversation Business levelNative level12 3 45Reading : NoneSome words Simple sentences Short storiesNewspapers12 3 45Writing : NoneSome words Simple sentences Short essaysBusiness reports12 3 45JAPANESESpeaking : NoneGreetings Basic communication Everyday conversationBusiness level12 3 45Listening: NoneGreetings Basic communication Everyday conversationBusiness level12 3 45Reading : NoneSome letters Simple sentences Short storiesNewspapers12 3 45Writing : NoneSome letters Simple sentences Short essaysBusiness reports12 3 45 Do you use or understand any of the followings? Please tick all appropriate boxes below. Braille: %Native language ( ) %English (Grade ) %Japanese %Other (please specify : )  Sign language: %Native language ( ) %ASL %International %Japanese %Other (please specify : ) Lip-reading: %Native language ( ) %English %Japanese %Other (please specify : ) If you have any other communication skills, please describe below :  24. Referee information  Give the name and contact details of your referee. Name: Relationship to you : Address : Occupation : Email: Telephone: Mobile phone: 25. Surety information  Give the name and contact details of your surety. Name: Relationship to you : Address : Occupation : Email: Telephone: Mobile phone: 26. Who completed this application form?I completed this form by myself. I got help  please give details on the person who completed this form on behalf of you. Name: Relationship to you : Reason for assistance: 27. Have you applied for this program before? Yes, I applied in 20 No, this is my first time applying.28. Declaration statement by the applicant I hereby certify that all the information stated above is true, correct and complete. 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