Japan Atomic Energy Agency

JAPAN ATOMIC ENERGY AGENCY

FOREIGN NATIONAL VISIT PROPOSAL

Applicant is required to fill inPart A, B, C and D in English or Japanese, then send to JAEA contact.
Part A. Personal information
1. Application date (mm/dd/yyyy)
2. Name of visitor (Last, First, Middle) / 3. Date of birth (mm/dd/yyyy)
4. Nationality / 5. Place of birth (City, Country) / 6. Gender
□ Male □ Female
7. Permanent resident address (Street, City, Country)
8. Passport number / 9. Passport expiration date (mm/dd/yyyy)
10. Field of expertise
Part B. Employment information
1. Name of organization
2. Address (Street, City, Country)
3. Telephone / 4. Fax / 5. E-mail address
6. Job title
Part C. Visit information
1. Date of visit (mm/dd/yyyy)
From 09/17/2010 To 09/17/2010
2. Objective of visit
J-PARC tour
3. Visit site (e.g.: Tokai R&D Center)
Tokai R&D Center / 4. Visit facility (e.g.: J-PARC)
J-PARC
5. If you have visited JAEA before, specify site and facility, and the year of latest visit.
Part D. Additional information
If you are visiting facilities subject to physical protection, please obtain signature of your supervisor inyour organization or your guarantor in Japan. (In principle, JAEA staff can not be your guarantor.)
1. Name of organization
2. Name of supervisor/guarantor (Last, First, Middle)
3. Address (Street, City, Country)
4. Telephone / 5. E-mail address
6. Job title / 7. Signature

JAPAN ATOMIC ENERGY AGENCY

FOREIGN NATIONAL VISIT PROPOSAL

Example for a Delegate

Applicant is required to fill inPart A, B, C and D in English or Japanese, then send to JAEA contact.
Part A. Personal information
1. Application date (mm/dd/yyyy)
07/29/2010
2. Name of visitor (Last, First, Middle)
Doe, John / 3. Date of birth (mm/dd/yyyy)
07/29/1970
4. Nationality
USA / 5. Place of birth (City, Country)
Blackacre, USA / 6. Gender
X Male □ Female
7. Permanent resident address (Street, City, Country)
100 Blue Avenue, Whiteacre, USA
8. Passport number
AB12345678 / 9. Passport expiration date (mm/dd/yyyy)
07/29/2012
10. Field of expertise
Beam dynamics
Part B. Employment information
1. Name of organization
Greenacre University
2. Address (Street, City, Country)
100 Gray Avenue, Greeenacre, USA
3. Telephone
1-234-5678 / 4. Fax
1-234-8765 / 5. E-mail address

6. Job title
Professor
Part C. Visit information
1. Date of visit (mm/dd/yyyy)
From 09/17/2010 To 09/17/2010
2. Objective of visit
J-PARC tour
3. Visit site (e.g.: Tokai R&D Center)
Tokai R&D Center / 4. Visit facility (e.g.: J-PARC)
J-PARC
5. If you have visited JAEA before, specify site and facility, and the year of latest visit.
J-PARC, 2008
Part D. Additional information
If you are visiting facilities subject to physical protection, please obtain signature of your supervisor inyour organization or your guarantor in Japan. (In principle, JAEA staff can not be your guarantor.)
1. Name of organization
2. Name of supervisor/guarantor (Last, First, Middle)
3. Address (Street, City, Country)
4. Telephone / 5. E-mail address
6. Job title / 7. Signature

JAPAN ATOMIC ENERGY AGENCY

FOREIGN NATIONAL VISIT PROPOSAL

Example for a Companion

Applicant is required to fill inPart A, B, C and D in English or Japanese, then send to JAEA contact.
Part A. Personal information
1. Application date (mm/dd/yyyy)
07/29/2010
2. Name of visitor (Last, First, Middle)
Doe, Jane / 3. Date of birth (mm/dd/yyyy)
07/29/1970
4. Nationality
USA / 5. Place of birth (City, Country)
Blackacre, USA / 6. Gender
□ Male X Female
7. Permanent resident address (Street, City, Country)
100 Blue Avenue, Whiteacre, USA
8. Passport number
AB9876543 / 9. Passport expiration date (mm/dd/yyyy)
07/29/2012
10. Field of expertise
N/A
Part B. Employment information
1. Name of organization
2. Address (Street, City, Country)
100 Blue Avenue, Whiteacre, USA
3. Telephone
1-234-9876 / 4. Fax
1-234-9876 / 5. E-mail address

6. Job title
Spouse of Doe, John
Part C. Visit information
1. Date of visit (mm/dd/yyyy)
From 09/17/2010 To 09/17/2010
2. Objective of visit
J-PARC tour
3. Visit site (e.g.: Tokai R&D Center)
Tokai R&D Center / 4. Visit facility (e.g.: J-PARC)
J-PARC
5. If you have visited JAEA before, specify site and facility, and the year of latest visit.
Part D. Additional information
If you are visiting facilities subject to physical protection, please obtain signature of your supervisor inyour organization or your guarantor in Japan. (In principle, JAEA staff can not be your guarantor.)
1. Name of organization
2. Name of supervisor/guarantor (Last, First, Middle)
3. Address (Street, City, Country)
4. Telephone / 5. E-mail address
6. Job title / 7. Signature