日本国际协力机构(JICA) 2010年度青年研修项目(基层工作者邀请计划) 申请表 ★本表须在电子版上直接输入, 若手写要求字迹清晰、 工整。 A 申请人简历 (Details of Applicants) 姓名(应与护照名一致, Write the same name to the passport) (1)姓(拼音字母) (2)名(拼音字母) (3)姓名(汉字) (4)爱称 (Nick name) (5)性别 □男 □女 (6) 国籍:中国 (7) 民族: (8)出生年月日: 19 年 月 日(满 岁) (9)婚姻状况 □已婚 □未婚 (10)家庭住址(Home Address): 邮编(Zip-code): TEL: 手机(Mobile): (11)紧急联络人信息(Person to notify in case of an emergency) 姓名(Name) 与申请人关系(Relationship to you) TEL: 手机(Mobile): (12)访日经验 (不包括本次访日经历, Experience to visit Japan) □无(No) □有(Yes) (时期 年 月、 期间: 、 访日目的: ) (13)外语水平 (Language Proficiency) 英语 (English) : □流畅(Excellent) □能听懂(Fair) □听不懂 (Poor) 日语 (Japanese) : □流畅(Excellent) □能听懂(Fair) □听不懂 (Poor) (14)取得最终学历的学校名及所学专业(academic record; school which you are attending or last attended) □大学以上 (University) □大专 (College) □中专 (Polytechnic) □高中 (High school) □其他(other) (15)兴趣爱好&体育活动 (Hobby and Sports) (16)宗教 (Religion) □无(No) □有(Yes) (17)食物忌讳(I can’ t eat foods stated below): □有(Yes)□无(No) 选择「有」 的申请人请填写下列事项。(此项不包括个人对食物的喜恶) ❈ 此项不能空栏 ・ 猪肉(Pork) :□宗教原因 □过敏(allergy) □其他原因(others) ・ 牛肉(Beef) :□宗教原因 □过敏(allergy) □其他原因(others) ・ 其他食物(others) :□宗教原因 □过敏(allergy) □其他原因(others) B 工作情况(Job Record) (1) 所属单位名称(用汉字填写) (Name of Organization): 1. 请在此粘贴与中国护照像尺寸相同的相片 2. 请在相片的后面填写 姓名 (用英文填写) (Name of Organization): (2) 所属部门名称(用汉字填写) (Name of Section): (用英文填写) (Name of Section): (3) 联系地址(Contact Address): 邮编(Zip-code): TEL: FAX: E-mail: (4) 职业与职务(用汉字填写) (your post) (用英文填写) (your post) (5) 请介绍所属单位的业务与活动状况及本人的业务经历、 单位规模以及现在的业务内容等 (Describe your work/activities relevant to the group category for which you are applying; Include information such as experience/careers in the field, your post, number of staff and current task you are handling) (6) 请介绍您希望通过参加本项目所要学习的内容, 并计划将本次访日成果如何运用到今后的工作及生活中(如该篇幅不够请另附一页) (Describe what you want to gain from the program and how you shall make use of the program’ s expected achievements) C 既往病史(Medical Record) *因本项目含各种室外参观及野外活动, 所以主办方认为不适合孕妇参加。 (As the schedule of this program includes many field trips and activities which may cause some complications for pregnant women, pregnancy is regarded as a disqualifying condition for participating in this program. ) 1. JICA对隐瞒既往病史而发病者不给予经济上的保障并可能中止其参加本项目。 您是否理解并接受此项规定? (A medical condition resulting from an undisclosed pre-expecting condition will not be financially compensated by JICA and may result in termination of participation in the program. Do you understand and accepted terms of this notice? ) □理解而接受YES □不理解所以不接受NO 2. 请根据您现在的健康状况填写下列各项(Mark the boxes below according to your present health condition) A. 哮喘病Asthma □YES □NO B. 肺气肿Emphysema □YES □NO C. 肺结核Tuberculosis □YES □NO D. 高血压High blood pressure □YES □NO E. 心脏病Heart Disease □YES □NO F. 肝炎( 型)Hepatitis □YES □NO G. 胆囊炎Gall bladder disease □YES □NO H. 肾脏病Kidney Disease □YES □NO I. 膀胱炎Bladder Disease □YES □NO J. 尿结石或血尿Stones or blood In urine □YES □NO K. 糖尿病(尿糖)Diabetes(sugar in urine) □YES□NO L. 抑郁症Depression □YES □NO M. 神经衰弱Excessive worry □YES □NO N. 肿瘤Tumor □YES □NO O. 发育不正常Abnormal growth □YES □NO P. 囊肿Cyst □YES □NO Q. 癌症Cancer□YES □NO R. 不正常出血Bleeding Disorder □YES □NO S. 血液病Blood disease □YES □NO T. 爱滋病AIDS) □YES □NO 3. 您现在是否因健康状况的治疗而服用任何药物?(Do you currently take any medicines for treatments?) □NO □YES 药物名称(name of medicine) 服用量 目的 4. 您是否患过严重疾病或受过重大伤害?(Have you ever had any significant or serious illness or injury?) □NO □YES 何时 具体状况 5. 您是否动过手术或医生建议您动手术? (Have you had any operations or advice by a physician to have an operation?) □NO □YES 何时 具体状况 6. 您是否曾是精神病院或疗养院的患者或被作为精神病患者对待? (Have you ever been a patient in a mental hospital or sanitarium or treated by a psychiatrist?) □NO □YES 何时 诊断情况 7. 请在下列两项中选择一项。 (Mark one of the boxes below which describes your medical statement) □我在健康上没有问题, 适合参加本项目 (I don’ t have any health problems to prevent me from participating in the program) □我在健康上有问题, 我担心发生如下情况(I am worried about……. . ) : D 誓约书 (Statement of pledge) 我, (姓名)