See the Application Guidelinesfor the Details and Describe the Following Information In

1. Study Course

See the Application Guidelinesfor the details and describe the following information in the table below.

Priority / (1)Area
A: Agriculture
B: Engineering
C:Social Science
D: Education
E: Health / (2)
Field of Study / (3)
SRF code / (4)
Specific Research Field / (5)
Univ.Code / (6)
Name of selected University and
Graduate School / (7)
Supervisor you wish to be instructed
Ex. / B / Architecture / 134 / Urban Engineering / 49 / PEACEUniversity,
Graduate School of Engineering / Professor
Taro Yamada
1st
2nd*

* Male candidates in the field of social science (SRF code 301~325) can apply only for the first-choice university.

2. Basic Information

1) Name(as in the passport)

Family Name

First Name

2) Nationality
(as shown in the passport) / 6) Date of Birth and Age (as of 1 Sep. 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
7) Contact (Private) / Mobile (Cell Phone): / E-mail:

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) / 5) Date of Birth and Age (as of 1 Sep. 2018)
(please write out the month in English as in “April”)
3) Sex / ( ) Male / ( ) Female / Date / Month / Year / Age
4) Religion

7) Present Position and Current Duties

Organization
Department / Division
Present Position
Date of employment by the present organization / Date / Month / Year / Date of assignment to the present position / Date / Month / Year

8) 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

9) Contact Information

Office / Address:
TEL: / Mobile (Cell Phone):
FAX: / E-mail:
Home / Address:
TEL: / 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 / 9/2000 to 6/2004
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
Other Higher Education (except training) / / to /
Month/Year Month/Year

*Do not count short course/training course.

Total Years of Education: ______year(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)Have you ever studied overseas?

[ ] Yes →Name of the country:

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 provided by PEACE.

[ ] Yes →Name of the Training:
Country you visited: Duration From (month/year) – To (month/year)
[ ] No

(6)Have you applied PEACE before? (except in case of failure in internal selection at your organization) (1st batch 2011, 2nd batch 2012, 3rd batch 2013, 4th batch 2014, 5th batch 2015, 6th batch 2016 or 7th batch 2017)

[ ] Yes →Batch :
[ ] 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 / Working Period / From /To
(Month/Year) / Type* / Grade**
(E.g.) Ministry of XXX
*Do not abbreviate the name of Organization nor Department. / Engineering Department
*Do not abbreviate the name of Organization nor Department. / Assistant Director / 2 years and
3 months / 4/2008 to 6/2010
Month/Year Month/Year / A / 3
(Current Ministry) / (Current department) / (Current position) / / 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

**If it is a governmental position, write the grade of the position.

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.]

(2) Do not forget your signature on each page of the attachments.

(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. Research Plan

(1) Write a proposal of your study plan and research plan for your Master’scourse.

Please follow the instruction which is the Application Guideline. (see page 47- 48)

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.

8-1. Title of your Master’s thesis or Research(Study) Plan:

8-2. Write your proposed Research Plan below:

9. 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: / Signature:
Print Name:

10. 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:

1. 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.
2. All the information provided by me in this Application Form had been approved by my supervisor in my Ministry/Organization.
3. An Application Form which is incomplete or missing any necessary documents will be deemed ineligible and not considered.
4. 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.
5. 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.
6. 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 Research student/ Master’s student.
7. The objective of the PEACE Project is to provide Afghan citizens to study in Japan at master’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 degree in Japan.
8. 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 the Guidelines of Application.

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.

1. 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.
2. to understand 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)_____

Signature of Applicant: