Entry Form For JENESYS 2.0

Entry Form for JENESYS 2.
0
Science and Technology ( 8th Batch)
1. Personal Information
Name
Photo
(taken within 3
months)
Please
write your
name on the
back of your
photo.
* Please fill in the form in BLOCK LETTERS

Full Name (Exactly the same as your passport)
IZZUR ROZABI
Given name (English)
Family Name (English)
IZZUR
ROZABI
Full Name (in Mother language)
IZZUR ROZABI
Date of Birth
2/12/1991
Nationality
Religion
INDONESIAN LANGUANGE
Buddhist
Hindu
Christian (Roman Catholic Protestant Other)

Muslim
Others (
INDONESIAN LANGUANGE
Mother Tongue
Marital Status
Type of Passport
Number
Private
Passport**
Current Address
Contact Person
in Emergency
*It shall be your parent.

*If you live with him/her,
please leave address
blank.
Date of Issue
(28)
(01)
(2014)
Diplomat
Date of Expiry
(28)
(01
Address
JALAN UNTUNG SURAPATI 63, RT 001/ RW 002, PASURUAN , JAWA TIMUR
Tel : -
Fax
Mobile :
Full Name
ABDUL CHAMID
E-mail
Address
JALAN UNTUNG SURAPATI 63, RT 001/ RW 002, PASURUAN , JAWA TIMUR
Tel
Fax
Japan International Cooperation Center EF ver.2(April 9, 2013)
in Emergency
blank.
Mobile :
E-mail
Profession/Occupation
*If you do not have phone Name
ENTREPRENEUR
Phone Number
at your current address,

please write contact
person and number.
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
2.Health Condition
Blood Type
* Please fill in the form in BLOCK
A B O AB
don't-know
Good
Previously diagnosed disease:
(
Health Condition
Medicine
Pregnancy
Having Chronic disease:

chronic lung disease (asthma, chronic obstructive lung disease etc.)
immunodeficiency state (T cell immunodeficiency etc.)
chronic heart disease (congenital heart disease, coronary artery disease etc.)
metabolic disease (diabetes) renal dysfunction obesity myasthenia gravis
others (
)
Not taking any medicines

Taking medicines regularlly (Specified
Yes No
none
Food Allergies
pork beef chicken
(only for physical reason)
fish egg others (
mutton/lamb
shrimp
crab shellfish
)
none
Food Restriction
(for religion or
custom reason)
pork
beef
fish egg
chicken
mutton/lamb
others (
shrimp crab shellfish

)
*Please be noted that the meals provided in the programme cannot meet all the requests from
Other Allergies and none

Restriction
dogs
cats
house dust
others (
3. Academic Details
Name of School or Organization

BRAWIJAYA UNIVERSITY
Information of your
School/Organization
Field of study(for university student only)

ECONOMIC DEVELOPMENT
Grade/school year (for student)
as of the day of the flight to Japan
4th
Title (for supervisor only)

English Proficiency
certificated score (if any, e.g. TOEFL)
Level of English
540
Level of Ja
Language
Speaking: Good
Fair
Poor
Speaking: Good
Fair
Writing : Good
Fair
Poor
Writing : Good
Fair
Reading : Good
Fair
Poor
Reading : Good
Fair
Other Language
Japanese
learning
experience
4. Personal Activities
Activities
Sports/Clubs
Hobbies
Academic Awards
(if any)
1. Center For Islamic Economis Studies Faculty of Economics and Business

University Of Brawijaya
2. Student Association of Economic Development Faculty of Economics and
Business University Of Brawijaya
3. LSO RISTEK EM UB
4. MANAJER HRD UNITAS RKIM UB
5. DIRECTOR UNITAS RKIM UB
6. MASYARAKAT ILMUWAN DAN TEKNOLOG INDONESIA KLASTER MAHASISWA
7. INDONESIAN MUSLIM UNITY STUDENT ACTION of UNIVERSITY OF BRAWIJAYA
READING BOOK, WRITING BOOK, AND PUBLIC SPEAKING
1. FINALIST PKM-GT Krima

2. Business plan competition 2010 let your mind guide your future
2. PKM-GT Maba Level Of Faculty
3. Business Funding Grants OfMandiri Bank
4. PKM-GT Maba Level OF University
4. Indonesian Student Entrepreneurship Award create and make IT different
Indonesian Bussiness Expo and Competition (IBEC) 2011
5. LKTI Accounting Days 2011
6. Best Paper di Sector Education Call For Paper SimposiumNasionalKepemudaan (IPB
2011)
7. Wismilak Diplomat Session II Regional Surabaya
8. Creative Business Plan Management Event 2011
9. Cerpen Para Pencari Tuhan di Jepang
10. National Writing Competition on Indonesia-Marocco
11. International Conference Faculty of Economic and Business
12. International Conference Sharia Economics Event South East Asia
13. Forum Satya Daya-ITB Fair 2012
14. Training RKIM I Spirit to Accelerate
15. Training Presentations Of PKM
16. Finalis Market and Sell Competition ITS 2012
17. Best Implementation Business Dinar Tazkia 2012
18. Finalis Business Plan Competition AMIKOM
19. WRITING BOOK : Mengikat Makna Diantara Gempa Literasi
20. Presenter in The 1st International Seminar on Quality and Affordable Education 201
21. IRSA International Conference
22. Business Plan Contest at SOI Asia 2012 2013
23. WRITING BOOK : Percikan Api Sejarah
24. Business Funding Grants OfMinistryOfEconomic
25. WRITING BOOK : Catatan Kecil Antara Islam dan Jepang
5. Expectations
Imitate Samurai Culture in Japan

The figure of a Japanese samurai figures are very fabulous. They are very disciplined, ob
a leader but still have the strong principle. The figures are able to give their lives for th
with punctuality in others. The figures were shy, very shy when war came, but they did n
are all samurai warriors in Japan.
Discipline and his willingness to risk his life, was a resounding impact on the outcome in
discipline to bring them into the human history is not forgotten. Which is rooted in t
civilization. History of the Samurai is a very difficult history to be forgotten any age the
always inspiring.
Learning from the Japanese samurai is one of the objectives of joining in this program. B
the Japanese samurai that is the generation of today. When we look at Japan's highly de
it can be ascertained that all the fruit of the previous generation
Please describe your
Reflecting on the figures samurai in Japan. They are a very high-minded people and have
expectation by
In connection with the soul, in the tradition of samurai to find peace of mind, they prefe
participating in this meditation. Imprison ourselves, silent, and calm the mind through meditation, will produ
programme.
mind, clarity in thinking. They will get a clarity in thinking, calmness in the act, and
Related Learning a clarity in thinking, the Japanese are things that can not be liberated
very rooted. Write down the Japanese culture such as peace of mind and calm the mind,
that is read by the people of Indonesia is one way to popularize the Japanese
Gradually, the tradition of Japanese samurai were originally just as a waiter, the longe
create groups that eventually became a professional group of knights. The presence of
live independently makes them seek to take away the powers held by the other leade
each took it willingly. They compete with each other to grab the front of the image of Ja
determine who is the most powerful force. One example happened to the samurai cla
Minamoto clan launched an offensive to seize power Taira family. In fact they did a very
Dannoura which was eventually won by the Minamoto clan.
That is the lesson that if a Japanese samurai applied in Indonesia should be eliminated.
must be implemented, some are selected so that the negative is able to be learned. Fo
take lessons from both Japanese culture lessons in the field of the samurai is the profe
samurai. It is probable that the samurai who rebelled not because they wanted more pos
down by the current government.
In strata samurai in Japan, the higher the degree of a samurai, then he has a duty to ca
samurai sword more than usual. They studied a lot of literature, poetry, calligraphy, pai
For them, according to Boye, the higher the level of the samurai, the more important it i
Samurai eliminate the existence of strata and explore the science disciplines beyond the
Since the samurai victories in 794 AD they realized the importance of learning science
1467 AD.
Sure enough the Japanese are very experienced in the country's progress. The rapid pr
the scientific community will appreciate. Even in the Japanese culture in these modern
people who have the knowledge, they used to call 'sensei', or a person who acquired th
from professor likened powerful letters that can not be denied.
In the culture of the samurai in Japan, determination of purpose in moving is the most im
war. The first point presented by Musashi in a book by Boye, explained that we should h
the goal before, and the more difficult the objectives set, the more difficult it is for ways
it happen.
Learning the Japanese People goal setting is very important. By knowing the characteris
and applied in Indonesian people can be a breakthrough for Indonesian people. Provi
mission to the people of Indonesian.
Discipline is also applied by the samurai in Japan. Even, they educate teens to get used
maintaining mental discipline, physical, intellectual, and spiritual. The results of their d
the Japanese people at this time. Not hard for them to discipline. Related matter of time
for them. Just a little late, making them feel very embarrassed.
With the aim of knowing the basic principles of the Japanese People discipline, can also
subject discipline. With the culture and discipline of the Japanese culture was brought to
have incorporated Japanese culture into Indonesian society.
Courage pick samurai in death was a result of their psychological training to give death
is one of the transition to another level of existence. Even since the days of the samurai
education that death is better than failure and loss of self-esteem
Diligence conducted by the Japanese people from generation to generation, a trait pas
generations, the samurai. In his book, Boye explains that, major changes occurred to the
do through perseverance. For example, in just 20 years, between 1870-1890, the Japane
managed to change his country agriculture-based countries (agriculture), into a stat
We see just how the perseverance of Japanese society is not only limited to the histories
then forgotten period thereafter. However, the Japanese people to learn from the histor
made history as motivation for their passion, a lesson that can ripen them, the motivat
their morale.
Meanwhile, in 1945, we know that the State of Japan are experiencing severe crisis, na
Hiroshima City and Nagasaki City. Destruction of some parts of the two cities which had
in Japan, but do not destroy the spirit of its people. We know that until 1970, the Japa
managed to rebuild his country, but also almost able conguered world, which is a count
largest economy in the world.
Meanwhile, dozens of years later, when the State of Japan experienced a fairly complica
caused by them again, they could build their country back quickly. We watched the TV
able to rebuild after the tsunami hit in 2011.
How the Japanese Society is a world pilot communities at this time. Why is that? In th
chapter, we will try to discuss.
Samurai, Boye book, illustrated that they are not opposed to letting people do the rest
opportunity for opponents to gather strength, opportunity, and mind, as wel
Samurai war tactics were never the same, now the tactics for entrepreneurs in Japan
companies in Japan went bankrupt very powerful, even if only the mistakes that causing
left, would sink the Japanese and there will be no left of the company
However, the Japanese tactics without ever ending, implementing enterprise systems
opening branches that some children have a financial accounting system separately wi
the results are quite stunning and satisfying. Now, some of its subsidiary companies ar
finance the parent company that is experiencing a prolonged dying and should have e
possible. This is a fairly unique Japanese culture.
Samurai, sometimes show up so eagerly been doing battle enemy forces in order to feel
hand, they have enough tactics to trick his opponent, through the attitude that make
vigilance. Attitude carried by samurai is lackadaisical attitude and lack of spirit. Apparen
trap the opponent's stance.
Figures of samurai in battlefield, like a man who made himself into authorities battlefi
looking at all the possibilities that occur.
In his work, Boye said that a samurai who is only able to make himself as a person who
like a sparrow that inhabit nest roof of a house. There is no sharpness in search of pre
whole thing happening in the world, only able to reach the gardens around the house. M
samurai who is able to 'read the mind of your opponent', like an eagle that could fly soar
he was able to see from the height of the world how beautiful, how wide t
Not only that, apart from the pleasure of eagle that could fly high and see how beautifu
sky eagle fly, being able to see just how the enemies and prey are within its territory. T
dominate the battlefield, and even able to make your opponent eat a
Speaking related advances in Japan, the Japan People that Boye commenting can progre
they proved to be people at the forefront of deploying and running the learning concep
The Japanese Society has a very strong character in the work. Looking at the history of
that the character of the Japanese Society are hard working people that the normal
improvement even Japan are growing rapidly after about 20 to 30 years of the destruc
Nagasaki.
How could the country that has been torn apart in the second city, is able to restore th
increase it without the hard work of the government and public awareness. Obvious
apparently through the hard work of Japanese People go hand in hand, finally re-raised J
to rebuild its government. This is what we should make an example for the peop
Indonesia, a majority Muslim country, to date has experienced 60 years of independen
able to overcome the internal problems of the nation. There are still a lot of depravity
criminals who roam. This is a very unique country. Those who are guilty will be released
continue to be pursued until he is guilty. Very different from Japan. Islam is not wron
Indonesia who are Muslims who do not want to implement Islamic teachings that ma
Japan, which had only just begun not less magnitude. Dated March 11, 2011 yesterday,
huge earthquake with a strength of 8.9 which ultimately cause a tsunami. This is a new
the Sakura flowers. But what happened? They remain eager to build Japan
For car or motorcycle riders, they are still waiting in line to get fuel at a refueling point. T
ethics that they have built a long time. Can you imagine in Indones
Finally, history has proven that the Japanese are a resilient nation. How not, after repe
instead print the new histories.
We look at a new Japanese history since the second detonated his city, which is in the p
Tape initially underestimated the world, but was able legendary Sony Walkman product
created by Akio Morita is one proof that Japan was able to rise from adversity and read
with technology.
With this event, I hope to further explore the cultural conditions that exist in Japan to be
applied in Indonesia generally, and particularly the Muslim People. In my first visit to J
there, there are many lessons that I took, but especially those in the 'educational trip'.
education and technology. However, the short trip was able to inspire me to be able to w
"Small notes between Islam and Japan", and the soon come up book entitled "Samura
hoped that the trip-related education culture, heritage, and Japanese art, I could write
through a very deep interest in my country of cherry blossoms agains
Of this trip, I hope to provide many new insights about the culture, heritage and art in Ja
passing of in the event Jenesys, able to give me the opportunity to generate more mean
heritage, and art in Japan
6. Other Information
Have you ever been to Japan before?

If Yes, what was the purpose of the visit
and where did you visit?
Yes
No
If Yes, When
Educational Trip
*In principle, any candidates who have participated in JENESYS 2.0 before are not allowed to take part again.
Declaration
Reg.No.
2.0
h Batch)
n BLOCK LETTERS in English.

ur passport)
Middle Name (if any)(English)
Nickname (Please specify

the name you would like to be called)
IZZUR
Age
(as of the day

of the flight to
Japan)
23
MF
Sex
SingleMarried
Passport
ate
Diplomat
Expiry
(28)
(01)
Official
(2018)
AN , JAWA TIMUR
Relationship :
PARENTS
AN , JAWA TIMUR
E-mail
e section blank.
ll in the form in BLOCK LETTERS in English.
ase etc.)
sthenia gravis
shellfish
)
b shellfish
et all the requests from the participants.
Location: (city,province)
MALANG CITY, EAST JAVA
Tel: 0341573944
Fax:
540
Level of Japanese
g: Good
Fair
Poor
: Good
Fair
Poor
: Good
Fair
Poor
Year or Month
Period of
Involvement
ics and Business
of Economics and
STER MAHASISWA
SITY OF BRAWIJAYA
2010-2014
EAKING
2014
your future
ake IT different
2011
nalKepemudaan (IPB
ya
011
occo
Business
th East Asia
2010-2014
2
012
Literasi
dable Education 2012
13
mic
Jepang
pan
e very disciplined, obedient to the command
give their lives for their leaders, have met
came, but they did not participate in it. They
pan.
ct on the outcome in the war. And now, the
. Which is rooted in the history of world
orgotten any age thereafter. Their history is
ng in this program. Because of the impact of

at Japan's highly developed and disciplined,
previous generation.
ded people and have a very deep tranquility.
of mind, they prefer to seek peace through
meditation, will produce a very deep peace of
ness in the act, and the like advantages.
can not be liberated from a culture that is
and calm the mind, and is written in a book
ularize the Japanese in Indonesia.
s a waiter, the longer the fade when they
hts. The presence of those who are able to
d by the other leaders. Due to power, they
nt of the image of Japanese society. Fight to
ed to the samurai class professionals, the
n fact they did a very fabulous sea battle in
he Minamoto clan.
hould be eliminated. There is a culture that

ble to be learned. For Indonesian culture, to
samurai is the professional attitude of the
ey wanted more positions, but they were let
ment.
n he has a duty to carry out science science
etry, calligraphy, painting, and ceramic art.
e more important it is to study the sciences.
isciplines beyond the war began in 1467 AD
e of learning science outside of the war in
ogress. The rapid progress because of how

re in these modern times, really appreciate
son who acquired the title 'professor'. Letter
can not be denied.
moving is the most important in the conduct
ned that we should have managed to reach
difficult it is for ways to reach out and make
wing the characteristics of Japanese People,

nesian people. Provide a clear vision and
esian.
e teens to get used to the discipline, both in
The results of their discipline, as seen from
elated matter of time, time is really valuable
very embarrassed.
e discipline, can also determine the actual

lture was brought to Indonesia, indirectly we
ndonesian society.
aining to give death and assume that death
days of the samurai, they more often get an
d loss of self-esteem.
eneration, a trait passed down by previous
nges occurred to the Japanese for what they
870-1890, the Japanese people were initially
riculture), into a state-based industries.
mited to the histories of their ancestors, and
learn from the history of his ancestors, and
en them, the motivation which can improve
ing severe crisis, namely the destruction of

two cities which had been devastated areas
until 1970, the Japanese people not only
orld, which is a country that has the second
rld.
ced a fairly complicated problem that is not
We watched the TV screen that Japan was
it in 2011.
me. Why is that? In the last section in this
uss.
g people do the rest in the war. Provide an

ty, and mind, as well as suicide.
ntrepreneurs in Japan. Some of the major
mistakes that causing the bankruptcy of the
eft of the company name.
enterprise systems breed. The companies
ystem separately with the parent company,
sidiary companies are growing and able to
ng and should have ended with as soon as
nese culture.
orces in order to feel afraid, but on the other
e attitude that makes the opponent lose
ack of spirit. Apparently, the two are able to
e.
to authorities battlefield. How? That is by
at occur.
elf as a person who 'thinks in his own mind',
ness in search of prey, not able to see the
around the house. Meanwhile, the figure of a
le that could fly soar high into the sky, while
beautiful, how wide the world.
nd see how beautiful the world, rising to the
within its territory. The Eagles were able to
your opponent eat a meal.
mmenting can progress very rapidly because
g the learning concepts they have learned.
ing at the history of Japan, a clear evidence

ople that the normalization of economic
years of the destruction of Hiroshima and
, is able to restore the economy and even

awareness. Obviously not possible. But
nd, finally re-raised Japanese God to be able
example for the people of Indonesia.
years of independence, but have not been
till a lot of depravity here and there. Many
uilty will be released, and the innocent will
an. Islam is not wrong, but the people of
c teachings that makes Islam look guilty.
11, 2011 yesterday, Japan was rocked by a
unami. This is a new history for the State of
eager to build Japan together.
at a refueling point. They still give priority to
u imagine in Indonesia?
. How not, after repeatedly destroyed, but
ies.
ity, which is in the process of birth Cassette
ny Walkman product at that time. Products
m adversity and ready to conquer the world
t exist in Japan to be able to be learned and

. In my first visit to Japan, about five days
e 'educational trip'. The journey of medical
e me to be able to write a book with the title
ook entitled "Samurai Tarbiyah Prophet". I
se art, I could write a book works of others
rry blossoms against this.
heritage and art in Japan. Hopefully with my
generate more meaningful work on culture,
n
ll in the form in BLOCK LETTERS in Englis.
16-21/03/2013
onal Trip
Entry Form for JENESYS 2.0

(Japan
1. Personal Information
Photo
(taken within 3
months)
Please
write your
name on the
back of your
photo.

Full Name (Exactly the same as your passport)
English
TARO YAMADA
Name
Given name (English)
Family Name (English)
TARO
YAMADA
Full Name (in Mother language)
Date of Birth
Day/Month/Year 25/12/1989
Japanese
Nationality
Religion
Buddhist
Hindu
Christian (Roman Catholic Protestant Other)

Muslim
Others (
Japanese
Mother Tongue
Marital Status
Type of Passport
Number
TG123456
Passport**
Date of Issue
(Day)
3
(Month)
3
Private
(Year)
2010
Diplomat
Date of Expiry
(Day)
3
Offi
(Month)
3
kita shinjyuku 1-2-4, tokyo, Japan 123-0045

Current Address
Tel 03-999-9999
Fax 03-456-9999
Mobile 030-456-9999
E-mail taro@yamada.co.jp
Full Name
TAICHI YAMADA
Contact Person
in Emergency
Address
minami shinjuku 5-6-7, tokyo, Japan 123-0099
blank.
Tel 03-456-7890
Fax 03-456-7890
EF ver.2(April 9, 2013)
in Emergency
blank.
Mobile 03-456-7890
E-mail taichi@yamada.co.jp
Profession/Occupation:
*If you do not have phone
at your current address,
please write contact
person and number.
Name
Singer
Phone Number
**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.
2.Health Condition
Blood Type
A B O AB
don't-know
Good
Health Condition
Medicine
Pregnancy
Having Chronic disease:

chronic lung disease (asthma, chronic obstructive lung disease etc.)
immunodeficiency state (T cell immunodeficiency etc.)
chronic heart disease (congenital heart disease, coronary artery disease etc.)
metabolic disease (diabetes) renal dysfunction obesity myasthenia gravis
others (
)
Not taking any medicines

Taking medicines regularlly (Specified
Yes No
none
Food Allergies
pork beef chicken
(only for physical reason)
fish egg others (
mutton/lamb
shrimp
crab shellfish
)
none
Food Restriction
(for religion or
custom reason)
pork
beef
fish egg
chicken
mutton/lamb
shrimp crab shellfish
others (
*Please be noted that the meals provided in the programme cannot meet all the requests from the p
Other Allergies and none

Restriction
dogs
cats
house dust
others (
3. Academic Details
Name of School or Organization
Shinjuku high school
Information of your
School/Organization
Field of study(for university student only)
Grade/school year (for student)

as of the day of the flight to Japan
3rd
Title (for supervisor only)

English Proficiency
certificated score (if any, e.g. TOEFL)
Level of English
TOEFL 250
Level of Japanes
Language
Speaking: Good
Fair
Poor
Speaking: Good
Fair
Poor
Writing : Good
Fair
Poor
Writing : Good
Fair
Poor
Reading : Good
Fair
Poor
Reading : Good
Fair
Poor
Other Language
Japanese
learning
experience
4. Personal Activities
Activities
Sports/Clubs
ski
Hobbies
drawing the cartoon
Academic Awards
first prize in English contest
(if any)
5. Expectations
Please describe your

expectation by
participating in this
programme.
6. Other Information
Have you ever been to Japan before?
Yes
No
If Yes, When
If Yes, what was the purpose of the visit

and where did you visit?
*In principle, any candidates who have participated in JENESYS 2.0 before are not allowed to take part again.
Declaration
I hereby certify that the statements made by me in this form are true and correct to the best of my knowle
Signature:
Date:
24
10
/ 2012
(Day/Month/Yea
Agreement of the Application Guidelines for JENESYS2.0

I hereby agree to the qualifications of health conditions and the use of my personal information for the pu
operation of JENESYS2.0 in accordance with the Application Guidelines for JENESYS2.0.
Signature:
Date:
24
10
2012
(Day/Month/Ye
Reg.No.
fill in the form in BLOCK LETTERS.

as your passport)
TARO YAMADA
Middle Name (if any)(English)
DAVID
Nickname (Please specify
the name you would like to be called)
TARO
Age
(as of the day

of the flight to
Japan)
18
MF
Sex
SingleMarried
Passport
ate
Diplomat
Expiry
(Day)
3
Official
(Month)
3
(Year)
2010
-456-9999
taro@yamada.co.jp
Relationship
father
-456-7890
taichi@yamada.co.jp
Singer
E-mail
leave the section blank.
se etc.)
ery disease etc.)

myasthenia gravis
crab shellfish
)
crab shellfish
)
meet all the requests from the participa
Location: (city,province)
Tokyo
Tel: 03-567-1111
Fax: 03-567-1112
TOEFL 250
Level of Japanese
g: Good
Fair
Poor
: Good
Fair
Poor
: Good
Fair
Poor
Year or Month
Period of
Involvement
2 years
5 months
t to the best of my knowledge.
2012
(Day/Month/Year)
nal information for the purpose of the

YS2.0.
2012
(Day/Month/Year)

Entry Form For JENESYS 2.0

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Entry Form for JENESYS 2.

* Please fill in the form in BLOCK LETTERS

Given name (English)

Family Name (English)

Full Name (in Mother language)

Christian (Roman Catholic Protestant Other)

*It shall be your parent.

at your current address,

Japan International Cooperation Center EF ver.2(April 9, 2013)

* Please fill in the form in BLOCK

Having Chronic disease:

Not taking any medicines

shrimp crab shellfish

Other Allergies and none

* Please fill in the form in BLOCK

Name of School or Organization

Field of study(for university student only)

Title (for supervisor only)

Japan International Cooperation Center EF ver.2(April 9, 2013)

Japan International Cooperation Center EF ver.2(April 9, 2013)

* Please fill in the form in BLOCK

1. Center For Islamic Economis Studies Faculty of Economics and Business

READING BOOK, WRITING BOOK, AND PUBLIC SPEAKING

1. FINALIST PKM-GT Krima

Japan International Cooperation Center EF ver.2(April 9, 2013)

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Imitate Samurai Culture in Japan

Japan International Cooperation Center EF ver.2(April 9, 2013)

Japan International Cooperation Center EF ver.2(April 9, 2013)

Japan International Cooperation Center EF ver.2(April 9, 2013)

Japan International Cooperation Center EF ver.2(April 9, 2013)

* Please fill in the form in BLOCK

Have you ever been to Japan before?

Japan International Cooperation Center EF ver.2(April 9, 2013)

n BLOCK LETTERS in English.

Middle Name (if any)(English)

Nickname (Please specify

(as of the day

Japan International Cooperation Center EF ver.2(April 9, 2013)

Japan International Cooperation Center EF ver.2(April 9, 2013)

ll in the form in BLOCK LETTERS in English.

et all the requests from the participants.

ll in the form in BLOCK LETTERS in English.

Japan International Cooperation Center EF ver.2(April 9, 2013)

ll in the form in BLOCK LETTERS in English.

ics and Business

Japan International Cooperation Center EF ver.2(April 9, 2013)

ll in the form in BLOCK LETTERS in English.

ng in this program. Because of the impact of

Japan International Cooperation Center EF ver.2(April 9, 2013)

hould be eliminated. There is a culture that

ogress. The rapid progress because of how

wing the characteristics of Japanese People,

Japan International Cooperation Center EF ver.2(April 9, 2013)

e discipline, can also determine the actual

ing severe crisis, namely the destruction of

Japan International Cooperation Center EF ver.2(April 9, 2013)

g people do the rest in the war. Provide an

Japan International Cooperation Center EF ver.2(April 9, 2013)

ing at the history of Japan, a clear evidence

, is able to restore the economy and even

t exist in Japan to be able to be learned and

ll in the form in BLOCK LETTERS in Englis.