＜Attachment1-2＞

/
JFY 2014Primary Course
APPLICATION FORM
(non-Japanese participants) /
INSTRUCTIONS: Please answer each question clearly and completely.
Type or print in ink.Write in English.Read carefully and follow all directions.
  1. Name

Family / Last name / Given / First name / if any, Middle name and/or Maiden name
Is the above name exactly as it is in your passport and other legal documents? YES NO
Date of Birth (DD/MM/YYYY) / 3.Place of Birth (City, Country) / 4. Sex
Male Female
5. Nationality(ies) at birth / 6. Present nationality (ies) / 7. Marital status
Single Married
8. Present title / Organization
9. Office address
Telephone number: E-mail:
Any objections to HPC contacting you at office? YES NO
10. Permanent address
Telephone number:
11. Present address (if different from item 10)
Telephone number: E-mail:
12. What is the specific reason for which you wish to participate in the Primary Course?
13.What do you most stronglyexpect to gain from the Primary Course?
14. Knowledge of languages
What is your mother tongue?
Other languages / Exam Scores (Indicate exam types) / READ / WRITE / SPEAK / UNDERSTAND
Easily / Not easily / Easily / Not easily / Easily / Not easily / Easily / Not easily
15. Education
A. University or equivalent
Name, Place and Country / Attended from/to / Degrees and academic distinctions obtained / Main course of study
MM/YYYY / MM/YYYY
B. Schools or other formal training or education from age 14 (e.g. high school, technical school or apprenticeship)
Name, Place and Country / Type / Attended from/to / Certificates or diplomas obtained
MM/YYYY / MM/YYYY
16. List professional societies and activities in civic, public or international affairs.
17. List any significant publications you have written (do not attach).
18. Employment: Starting with your present post, list in reverse order every employment you have had. Use a separate block for each post. Include also service in the armed forces and note any period during which you were not gainfully employed. If you need more space, attach additional pages of the same size.
A. Present post (Last post, if not presently in employment)
From / To / Exact title of your post / Type of business
MM/YYYY / MM/YYYY
Name of employer / Name of supervisor
Address of employer / Number and kind of employees supervised by you / Reason for leaving
Description of your duties
B. Previous posts (in reverse order)
From / To / Exact title of your post / Type of business
MM/YYYY / MM/YYYY
Name of employer / Name of supervisor
Address of employer / Number and kind of employees supervised by you / Reason for leaving
Description of your duties
From / To / Exact title of your post / Type of business
MM/YYYY / MM/YYYY
Name of employer / Name of supervisor
Address of employer / Number and kind of employees supervised by you / Reason for leaving
Description of your duties
From / To / Exact title of your post / Type of business
MM/YYYY / MM/YYYY
Name of employer / Name of supervisor
Address of employer / Number and kind of employees supervised by you / Reason for leaving
Description of your duties
19. References: List three persons who are familiar with your character and qualifications
Full name / Full address
(include email address and telephone number) / Business or occupation
20. State any other relevant facts, including information regarding any residence outside the country of your nationality.
21. Have you ever been arrested, indicted, or summoned into court as a defendant in a criminal proceeding, or convicted, fined or imprisoned for the violation of any law (excluding minor traffic violations)? If “yes”, give full particulars of each case in an attached statement.
YES NO
22. I certify that the statements made by me in answer to the foregoing questions are true, complete and correct to the best of my knowledge and belief.
Date: Name:
N.B. You may be requested to supply documentary evidence which supports the statements you have made above. Do not, however, send any documentary evidence until you areasked to do so and, in any event, do not submit the original texts of references or testimonials unless they are requiredfor the sole use of this application.

Number (for official use)：

＜Attachment 1-3＞

Covenant

(For Participants in the Primary Course)

To the Director of the International Peace Cooperation Division of the Ministry of Foreign Affairs of Japan

To the Program Director for the 2014“Program for Human Resource Developmentfor Peacebuilding,”Hiroshima Peacebuilders Center

I hereby pledge to make my utmost effort to work in the field of peacebuildingin the future after completing the course requirements for “The Program for Human Resource Development for Peacebuilding.” I have read andfully understood the Application Guidelines, and pledge the following:

1. To observe instructions and guidance by the Hiroshima Peacebuilding Center (hereafter HPC), other organizers, lecturers, instructors and any other persons in the position of instructing during the course, in order to achieve the goals of the program;

2. To respect the security situation, and to observe the laws of countries where the program is held, regulations set by the HPC and other organizers;

3. To compensate, with designated insurance or other appropriate means,the HPC, other organizers or third parties for any damage caused intentionally by me or through my negligence during the program;

4. To abstain from claiming against the HPC, other organizers or the related institutions for damages caused by unavoidable accidents such as natural or man-madecalamities, traffic accidents, disease, crime, etc. during the program even after exhausting the designated insurance;

5. To abstain from engaging in activities concerning politics, proselytizing or personal gainwhile holdingthestatus of a Program Associate;

6. To observe decisions by the Ministry of Foreign Affairs of Japan,the HPC and other organizersincluding aterminationof the program in the case of violation of this covenant or any inappropriate conduct;

7. To agree that the photos taken during the Primary Course may be used for the purpose of PR for the program.

Date:Signature:

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