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SCHOOLS ATTENDED
Please list all secondary and post-secondary schools you have attended. If you are currently enrolled
in an educational institution please indicate your expected graduation month and year.
If your highest level of education is secondary school please select “Other” under “School Type.” Under“Major/Concentration,” write “General Studies.”

1.

Date From:

Date To:

Name:

School Type:
Bachelors＝Undergraduate
Masters以上＝Graduate

Format: YYYY-MMor present

Major/Concentration:

Other:
Degrees, certificates or diplomas awarded/will be awarded:
該当しない場合は空欄のままにして下さい

2.

Date From:

Date To:

Name:

School Type:
Bachelors＝Undergraduate
Masters以上＝Graduate

Format: YYYY-MM
or presentMajor/Concentration:

Other:

Degrees, certificates or diplomas awarded/will be awarded:
該当しない場合は空欄のままにして下さい

3.

Date From:

Date To:

Name:

School Type:
Bachelors＝Undergraduate
Masters以上＝Graduate

Format: YYYY-MM
or present

Major/Concentration:

Other:
Degrees, certificates or diplomas awarded/will be awarded:
該当しない場合は空欄のままにして下さい

4.

Date From:

Date To:

Name:

School Type:
Bachelors＝Undergraduate
Masters以上＝Graduate

Format: YYYY-MMor present

Major/Concentration:

Other:
Degrees, certificates or diplomas awarded/will be awarded:
該当しない場合は空欄のままにして下さいPROFICIENCY IN FOREIGN LANGUAGES
Please check the level of knowledge appropriate for each language. List any others that may apply.
Please DO NOT include English if it is your native language.
Language

OralWriting

Reading1.

Other:
2.

Other:PREVIOUS INSTRUCTION IN FOREIGN LANGUAGES
1.

Other:

Date From:

Place:

Date To:

Type of educational
institution:

University, language school等

Format: YYYY-MM or present
Hours Per Week:

Certificates, diploma,
or credit received:

TOEIC, Bachelors, Masters等

2.

Date From:

Place:

Date To:

Type of educational
institution:

Other:
University, language school等

Format: YYYY-MM or present
Hours Per Week:

Certificates, diploma,
or credit received:
TOEIC, Bachelors, Masters等

3.

Date From:

Place:

Date To:

Type of educational
institution:

Other:
University, language school等

Format: YYYY-MM or present
Hours Per Week:

Certificates, diploma,
or credit received:
TOEIC, Bachelors, Masters等

EMPLOYMENT HISTORY
Include any work experience related to training field.

1.

Date From:

Employer: 必須

Street Address:

Date To:

Type of Business: 必須

Suite/Apt:

Format: YYYY-MM orpresent

Position Held/Title: 必須

Other:

Phone Number:

City: 必須

Description of Responsibilities and City/Country ofposition:

State/Province:

Maximum of 200 characters.
Postal Code:Country: 必須

2.

Date From:

Employer: 必須

Street Address:

Date To:

Type of Business: 必須

Suite/Apt:

Format: YYYY-MM orpresent

Position Held/Title: 必須

Other:

Phone Number:

City: 必須Description of Responsibilities and City/Country ofposition:

State/Province:

Maximum of 200 characters.
Postal Code:Country: 必須3.

Date From:

Employer: 必須

Street Address:

Date To:

Type of Business: 必須

Suite/Apt:

Position Held/Title: 必須

Other:

Phone Number:

City: 必須

Format: YYYY-MM orpresent

Description of Responsibilities and City/Country ofposition:

State/Province:

Maximum of 200 characters.
Postal Code:Country: 必須

PREVIOUS UNITED STATES VISA(S)

Have you ever obtained a U.S. visa?
Yes

No

Date From:

Visa Type and Purpose:

City:

Date To:

Sponsor:State:

Date From:

Visa Type and Purpose:

City:

Date To:

Sponsor:State:

Date From:

Visa Type and Purpose:

City:

Date To:

Sponsor:State:Have you ever been denied a U.S. visa?
Yes
If denied, please explain:
NoDo you have any U.S. visas currently pending?
Yes

No

Position Information
Internship/Practical Training Field:

Internship Start Date: Format: YYYY-MM-DD

Internship End Date: Format: YYYY-MM-DD

FINANCE
Personal Funds: For this section please enter the total amount of funding, either throughyour own savings or from your family, that you will have while you are in the U.S. This fieldcannot be left blank. If you are doing a paid internship, Cultural Vistas recommends aminimum of $3,000 total personal funds. For an unpaid internship, we recommend that you
have access to $1,000 - $2,000 per month, depending on your training location.
Total Host Company Compensation: (If applicable) enter the total amount of funds you arereceiving from your host company for the full duration of your program.
Government Funding: Please only enter an amount in this section if you are receiving
funds – either from your government or from the U.S. government – for the sole purposeof your upcoming training in the U.S. Do not include government scholarships that you arereceiving for university studies in your home country.
Total Personal Funds:※研修手当とは別に必要

Format: 0000.00
U.S. $

Host Company Compensation:

Format: 0000.00
U.S. $

Total Stipend or Scholarship
received from Government Sources:(研修期間の合計金額)

Format: 0000.00
U.S. $

派遣会社/団体、大学等(研修期間の合計金額)

Format: 0000.00
U.S. $

Others:(Describe below)
Name:(研修期間の合計金額)(研修期間の合計金額)

HOST COMPANY
Do you already have an established personal contact
at a company that you want us to contact on yourbehalf?

Company Name:

Street:City:

State/Province:

Postal Code:Country:

Contact First
Name:
Contact Last
Name:
ContactTelephone:Contact Fax:

Contact Email:YesNoESSAYS
Please answer the following questions in a paragraph of at least 3 – 4 complete sentences each. If
your essays are not long enough or you write bullet points, you will be asked to resubmit yourapplication.

What are some of the career goals you hope to achieve by completing an internship in the U.S.?:

What specific skills do you hope to learn in the U.S. that you would not learn in your home country
or another foreign country?:

Besides professional skills, what do you hope to gain from this internship?:

What benefits do you think your host company gains by hosting international trainees?: