Application For MIRAI Program 2019 Group 2 / 3 / 5

Please click the below link to see "Program Outline".
[Outline] (PDF/English only)
(*Please download and bring them to Japan)

Complete the necessary information below and click the 'Confirm' button.
* is mandatory component.

Privacy Policy * Agree
The personal information provided in this application will be handled in accordance to
the following standards of personal information set forth by JTB Corp. .
I read this Privacy Notice & Consent Form entirely and understand it absolutely,
and I hereby give my permission for the collection, access, use and processing of my personal data as described in this application.
Please click here to see Privacy Notice & Consent Form. (PDF/English only)

School Location (Country) *
Application of Program * Group 2 (Politics & Security / Period : 27 November - 4 December, 2019 / Application deadline : 5 October 2019)
Group 3 (Economics & Business / Period : 11 December - 19 December, 2019 / Application deadline : 15 October 2019)
Group 5 (Science & Technology / Period : 4 March - 11 March, 2020 / Application deadline : 20 January 2020)
1. Personal Information
[Note] Please enter your name as it appears on your passport.
Given Name (in ENGLISH) *
Family Name (in ENGLISH) *
Middle Name (if any) (in ENGLISH)
Preferred Name (If you have)
Gender * Male
Female
X
Date of birth * (dd/mm/yyyy)
e.g. 01/01/1994
Age * yrs old
*Age as of the day entering in Japan.
Issue Country of your passport *
Passport Number *
e.g. A123456
Date of Expiry * (dd/mm/yyyy)
e.g. 31/12/2020
Current Address
Address *
e.g. 123 MIRAI ROAD
State/Province *
e.g. , LONDON
ZIP code *
e.g. AA1A 1AA
Country *
TEL/Country code *
TEL/Mobile *
e.g. 020-1234-5555
E-mail address *
*Please enter PC e-mail address, if possible.
*Please set for receiving the following domain. '@jtb.com'

e.g. j.smith@mirai.co.uk

(For confirmation)
Contact Person in Emergency
Full Name *
e.g. PAUL GEORGE SMITH
Relationship *
e.g. FATHER
Address *
e.g. 123 MIRAI ROAD
State/Province *
e.g. , LONDON
ZIP code *
e.g. AA1A 1AA
Country *
TEL/Country code *
TEL/Mobile *
e.g. 020-1234-5678
E-mail address *
e.g. p.smith@mirai.co.uk
(For confirmation)
2.Health Condition
Food Restriction and Dietary Requirements * None
Halal
Vegan
Vegetarian
Beef
Pork
Chicken
Egg
Milk
Wheat
Shrimp
Crab
Shellfish
Fish
Any seafood
Other
Food Restriction and Dietary Requirements:For reason Allergies
Religious reason
On my preferences
*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.
Chronic disease * None
Having Chronic disease
*Medical treatment cost related to the chronic disease is not covered by the programme insurance.
Medical History * None
Having Medical history
Medication * None
Taking Medicines regularly
Smoking * Non-smoke
Smoke
*We might not be able to meet your request.
3.Academic Details
Information of your school
Name of School *
Location (City, Province) *
e.g. LONDON
TEL *
e.g. +44-02-9999-9999
FAX
e.g. +44-02-8888-8888
Department/Major *
Grade * Undergraduate
Graduate student
Ph.D
Language
Mother Tongue *
JLPT (Japanese-Language Proficiency Test) N1
N2
N3
N4
N5
*JLPT has been offered by the Japan Foundation and Japan Educational Exchanges and Services since
1984 as a reliable means of evaluating and certifying the Japanese proficiency of non-native speakers.

Other Japanese-language qualification
Name of qualifications
Grade
Proficiency in Japanese
Speaking Excellent
Good
Fair
Poor
Writing Excellent
Good
Fair
Poor
Reading Excellent
Good
Fair
Poor
Proficiency in Japanese Learning period
(Year or Month)

e.g. 1 YEAR
Other Information
Have you ever been to Japan before? * NO
YES
-If YES, When
e.g. 2010 / Jan - 2011 / Feb
Where
Purpose
Your SNS * Facebook
User name:
Instagram
User name:
Where is the nearest airport (Gateway Airport) from your school? * Airport
*IN / OUT is the same airport in principle.
*Please note that as a general rule the air ticket will be arranged from the nearest airport of your school.

Essay - Personal Statement
(Within 500 words) *

Declaration * Confirmed
I hereby certify that all the information given are true and correct.
I declare that I have read and understood the purpose and the content of this program I agree to participate in the program.
(Excluding those with health reasons, etc.)

Click "Confirm" button and go to the next confirmation page.

Note: Please be sure to click "Send" button in the bottom of the next confirmation page to submit your application and then exit.


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