＊Please sign all the pages on the right-hand corner
1. Category of Participant
(1) Ex-PEACE Participant [ ] batch
(2) Non Ex-PEACE Participant [ ]
2. Study Course
(1) Ex-PEACE Participants
Ex-PEACE Participants shall apply for the same supervisor and university/graduate school which they have completed a master’s degree through PEACE Project.
(2) Non Ex-PEACE Participants
Non Ex-PEACE Participants (new applicants) shallselect one of universities/graduate schools which were approved as accepting university of PEACE doctoral program. (Please refer to ‘Annex 1’ and ‘Reference 1’ attached in the Guidelines)
(1)AreaA: Agriculture
B: Engineering
C: Social Science
D: Education
E: Health / (2)
Research Field / (3)
Field
Code / (4)
Specific Research Field / (5)
Name of selected University and
GraduateSchool / (6)
Supervisor you wish to be instructed / (7)
Desired Name of Degree
Ex. / B / Civil Engineering / 123 / Water Engineering Construction / XXXXX University
Graduate School of Engineering / Professor
Taro Yamada / Doctor of Engineering
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※The above (2), (3) and (4) shall be filled based on the list of fields in P.2 of “Application Guidelines”.
※Before you decide university and supervisor, prior communication with the supervisor is required according to ‘Annex 3’ attached in the Guidelines.
Name (as in the passport)
Family Name
First Name
3. Personal Information
(1) Title
Project for the Promotion and Enhancement of the Afghan Capacity for
Effective Development (PEACE)
(2) Number (NOT need to fill in, JICA will inform after selection procedures)
J / -(3) Information about the Nominee
1) Name of Nominee (as in the passport)
Family Name
First Name
Middle Name
- / - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / - / -2) Nationality
(as shown in the passport) / 6) Date of Birth (as of 1st April 2018)
(please write out the month in English as in “April”)
3) Sex / ( ) Male / ( ) Female / Date / Month / Year / Age
4) Religion
5) Marital Status / ( ) Single / ( ) Married / ( ) Engaged
6) Present Position and Current Duties
OrganizationDepartment / Division
Present Position
Date of employment by the present organization / Date / Month / Year / Date of assignment to the present position / Date / Month / Year
7) Type of Organization
( ) National Governmental / ( ) Local Governmental / ( ) Public Enterprise( ) Private (profit) / ( ) NGO/Private (Non-profit) / ( ) University
( ) Other ( )
* MoHE…University, KM…Local Governmental, CRIDA and Others…National Governmental
8) Contact Information
Office / Address:TEL: / Mobile (Cell Phone):
FAX: / E-mail:
Home / Address:
TEL: / Your Mobile (Cell Phone):
FAX: / E-mail:
Contact person in emergency / Name:
Relationship to you:
Address:
TEL: / Mobile (Cell Phone):
FAX: / E-mail:
4. Educational Background
(1)Educational Background (as of application)
Level / Name of School Department / Location(City and Country) / Period of education you attended / From /To
(Month/Year) / Degree
(Ex.) / KabulUniversity
Faculty of Engineering / Kabul, Afghanistan / 4 Academic Years / 9/1999 to 6/2003
Month/Year Month/Year / Bachelor of
Engineering
(must be the same as in your certificate)Primary
Education / / to /
Month/Year Month/Year
Lower
Secondary
Education / / to /
Month/Year Month/Year
Upper
Secondary
Education / / to /
Month/Year Month/Year
Higher
Education
(Bachelor level) / / to /
Month/Year Month/Year / Bachelor of
Higher Education (Master level) / / to /
Month/Year Month/Year / Master of
Other Higher Education (except training) / / to /
Month/Year Month/Year
*Do not count short course/training course.
Total Years of Education: ______year(s) ______month(s)
(2)Have you ever been awarded any scholarship for studying abroad?
[ ] Yes →Name of the Scholarship:
Name of theOrganization the scholarship provided:
[ ] No
(3)The countryyou studied: Duration From (month/year) – To (month/year)
[ ] No
(4)Are you currently applying for any other scholarships?
[ ] Yes →Name of the Scholarship:
[ ] No
(5)Have you ever participated in any training course in Afghanistan or foreign countries including one implemented by JICA ?*Do not include the bridge education program of PEACE.
[ ] Yes →Name of the Training:
Country you visited: Duration From (month/year) – To (month/year)
[ ] No
5. Work Experience
(Fill out from the most recent and attach another sheet if the space is not enough. / Full-time job ONLY. Part-time job, full-time job before graduation of university, and period of suspension of work are not included. NOT ONLY that you have worked as civil servant BUT ALSO as private sector if any.)
(1)Work Experience (as of application)
Ministry/Authority/University / Department / Position / Period of Working / From /To
(Month/Year) / **Type
(E.g.) Ministry of XXXXX
/ Engineering Department / Assistant Director / 2 years and3 months / 4/2007 to 6/2009
Month/Year Month/Year / A
(Most recent) / / to /
Month/Year Month/Year
/ to /
Month/Year Month/Year
/ to /
Month/Year Month/Year
/ to /
Month/Year Month/Year
**For the type of organization above, choose the applicable alphabet below:
A. Ministry/Government B. National Research Institution/ Center
C. University (State) D. University (Private) E. Government Cooperation F. Others
Total Years of Work: ______year(s) ______month(s) (Side Job and Part-time Job are not included)
(2)Working Address:
(3)Working Phone: Fax:
6. What are (were) your responsibilities of your work?
(1)Your answer must be typedin 150 wordsor less[Maximum 1 (one) page.]
(Current Work)
(Previous Work)
7. Considering the specific field of study which you apply for on page 1, how will you utilize your knowledge, skills and experiences that you obtain in Japan on your return home for the contribution to the development of Afghanistan?
(1)Your answer must be typedin 400-500 words[Maximum 2 (two) pages.]
(2) If the space is not enough, use the next page in typing with computer or attach separate sheet of A4 sized paper to this page.
(3) Do not forget your signature on each page of the attachments.
8. Master’s thesis and your research experience
(1) Describe your summary of your Master’s thesis which you wrote in the master’s course
(2) The summary must be typed in no more than 700 words[Maximum 3 (three) pages.]
(3) Describe you research experience (if any)
A. Submit paper to academic society
B. Get publishedby a journal (Please describe as referred in scientific papers)
C. Cited by other researchers
(4)Do not forget your signature on each page of the attachments.
Title of your Master’s thesis:
9. Research Plan for Doctor’s thesis
(1) Write a proposal of your study plan and research plan for your Doctor’scourse.
The proposal must be typed in no more than 700 words[Maximum 3 (three) pages.]
(2) Use the next page in typing with computer /attach separate sheet of A4 sized paper to this page.
(3)Do not forget your signature on each page of the attachments.
Title of your Doctor’s thesis or Research Paper:
10. Reason to choose the Supervisor and University
(1)Describe the reason why you choose the supervisor
[Name of the supervisor]
[Reason]
(2)Describe the comments from your supervisor when you contacted and discussed your proposal.
(3)Describe the relationship between the university which you are applying for and your Ministry/University, or university which you graduated. (if any)
(Ex: MOU, Human exchange/Academic exchange program)
(4)Please describe information on university examination which you would like to apply for.
Contents / DetailsEligibility Screening before application / □Yes (Period of screening: from to )
□No
Application Period of the university / From to
Entrance examination / □Complete in Afghanistan
Please describe what kinds of examination will be taken (e.g. TV conference)
□Need to take exam in Japan
Date of exam in Japan:
Period of Enrolment / (e.g. April 2017)
11. Medical History
(1). Present Medical Status
(a) Do you currently use anymedicine or have regular medical checkup by a physician for your illness?
[ ] No / [ ] Yes: Name of illness ( ), Name of medicine ( )If yes, please attach your doctor's letter (preferably, written in English) that describes current status of your illness and agreement to join the program.
(b) Are you pregnant?
[ ] No / [ ] Yes: Months of pregnancy ( months)(c) Are you allergic to any medication or food?
[ ] No / [ ] Yes: What are you allergic to? ( )(d) Please indicate any needs arising from disabilities or using prosthesis that might necessitate additional support or facilities.
( )Note: You WON’T be disqualified due to disabilities. However, some universities ask the students to conduct experiments or field work that require physical strength. So, you may be directly inquired by the JICA official in charge for a more detailed account of your condition as necessary.
(2). Past Medical History
(a) Have you had any significant or serious illness?
[ ] No / [ ] Yes: Please specify ( )(b) Have you ever been a patient in a mental clinic or been treated by a psychiatrist?
[ ] No / [ ] Yes: Please specify ( )(3). Other Medical Problems
If you have any medical problems that are not described above, please indicate below.
I certify that I have read the above instructions and answered all questions truthfully and completely to the best of my knowledge.
I understand and accept that medical conditions resulting from an undisclosed pre-existing condition may not be financially compensated by JICA and may result in termination of the program.
Date / SignaturePrint Name
12. Declaration
I, (print your name) ______,
declare that I apply for PEACE Project with a full understanding of the “Application Guidelines for PEACE Project”, especially the articles stipulated below:
- All the information answered and provided in this Application Form by me is true and accurate to the best of my knowledge and ability. My Application will be cancelled if any information is proven to be false.
- All the information provided by me in this Application Form had been approved by my supervisor in my Ministry/Organization.
- An Application Form which is incomplete or missing any necessary documents will be deemed ineligible and not considered.
- All the selection procedure and its result are entirely entrusted to the secretariat of PEACE Project and any inquiry and objection by applicants regarding the result of selection are not accepted.
- If any act of dishonesty is found other than those above in the application and selection, I am to lodge no complaint about cancellation of the application.
- Under any condition, I will not change my Field of study/Specific Research Field during the selection process, after passing the selection process and as Doctor’s student.
- The objective of the PEACE Project is to provide Afghan citizens to study in Japan at master’s/Doctor’s level in order to support national efforts to achieve socio-economic development in Afghanistan. Thus, the returned participants are under the obligation to contribute to the development of Afghanistan and to remain in Afghanistan at least for the same period of his/her study in Japan after completing Master’s/Doctor’s degree in Japan.
- I agree that my personal information in the Application Form, provided to JICA, will be used when necessary for the purpose of the implementation of the PEACE Project.
Furthermore, if I am accepted as PEACE participant, I agree
(a)not to bring or invite any member of my family (except for a program whose period is one year or more),
(b)to carry out such instructions and abide by such conditions as may be stipulated by both the nominating government and the Japanese Government regarding the program,
(c)to follow the program, and abide by the rules of the institution or establishment that implements said program,
(d)to refrain from engaging in political activity or any form of employment for profit or gain,
(e)to return to my home country at the end of the activities in Japan on the designated flight schedule arranged by JICA,
(f) to discontinue the program if JICA and the applying organization agree on any reason for such discontinuation and not to claim any cost or damage due to the said discontinuation.
(g)to consent to waive any copyright holder’s rights for documents or products produced during the project, against duplication and/or translation by JICA, as long as they are used for the purposes of the program.
(h) to approve the privacy policy and the copyright policy mentioned in theGuidelines ofApplication.
JICA’s Information Security Policy in relation to Personal Information Protection
■JICA will properly and safely manage personal information collected through this application form in accordance with JICA’s privacy policy and the relevant laws of Japan concerning protection of personal information and take protection measures to prevent divulgation, loss or damages of such personal information.
■Unless otherwise obtained approval from an applicant itself or there are valid reasons such as disclosure under laws and ordinances, etc., and except for the following 1.-3., JICA will neither provide nor disclose personal information to any third party. JICA will use personal information provided only for the purposes in the following 1.-3 and will not use for any purpose other than the following 1.-3 without prior approval of an applicant itself.
1.To provideknowledge Co-Creation program to knowledge Co-Creation program participants from developing countries.
2. To provide knowledge Co-Creation program to knowledge Co-Creation program participants from developing countries under the Citizens’ Cooperation Activities..
3. In addition to 1. and 2. above, if the government of Japan or JICA determines necessary in the course of technical cooperation.
(i)to observe Japanese laws and ordinances during my stay, if I violate Japanese laws and ordinances, I will return the total amount or a part of the expenditure required for the training depending on the extent of the violation.
(j)tounderstand that JICA does not assure issuance of Japan entry visa even after JICA decide to accept me. I understand the Embassy of Japan will decide it according to necessary formalities upon the submission of visa application from each participant.
Signature: ______
(*Please sign at the bottom of all the pages including this page)
Date: (day)_____/(month)_____/(year)______
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Signature of Applicant: