Photo
45x35mm passport style
1. Name
Last First
2. Current Work Information
Institution/affiliation
Office / Division / Section
Title / Position
Work Phone Work Fax
E-mail Address
Are you currently on secondment from your home institution?
□ Yes
( name of the home institution
) ：
□ N o
3. Personal Information Date of Birth:
Age :
Sex
: □ Male
(
Month/ Day / Year
)
□ Female
Nationality : ＿＿＿＿＿＿＿＿＿＿＿＿ Passport Number : ＿＿＿＿＿＿＿＿＿＿＿＿
Expire Date : ＿＿＿＿＿＿＿＿＿＿＿＿
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Current country of Residency :: ＿＿＿＿＿＿＿＿＿＿＿＿＿
4. Home Address
Postal Code Prefecture/Province
City Street
Home Phone Home Fax
__________________________________
Mobile phone
E-mail Address (if different from work email)
5. Education List College, professional and special training (most recent first)
Name of Institution Dates Attended Major Degree
１．
２．
３．
6. Work Experience List your professional experience (most recent first)
Agency / Employer Dates Employed Exact Title
１．
２．
３．
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7. Summarize duties and responsibilities of your current position:
8. Overseas Experience Indicate below if you have traveled or lived abroad for work or education
Country / Location Dates of Residence Purpose
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9. English Language Ability
Please indicate your TOEFL/TOEIC score if you have taken either test.
TOEFL
____________________ _______________________
Total Score Date Tested
TOEIC
__________________ _______________________
Total Score Date Tested
Other (please specify) _______________________________________
Please provide an honest assessment of your English language proficiency in the following areas:

Reading (please circle appropriate response):
 I am able to read basic documents in my field Easily
I am able to read national daily newspapers Easily
With Difficulty
With Difficulty
Listening (please circle appropriate response)
 I am able to understand daily conversations Easily With Difficulty
 I am able to understand presentations and speeches Easily With Difficulty
Speaking (please circle appropriate response
 I am able to participate in simple conversations about the weather, family and transportation
Easily With Difficulty
 I am able to participate in conversations on current events and my professional areas
Easily With Difficulty
Other comments regarding your language proficiency:
10. Japanese Language Ability*
*Japanese proficiency is not required to take part in this program however if you have any Japanese experience, please indicate it here.
Japanese Language Proficiency Test (JLPT)
____________________ _______________________
Level Date Acquired
Please provide an honest assessment of your Japanese language proficiency in the following areas:
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
Reading (please circle appropriate response):
 I am able to read basic documents in my field Easily
I am able to read national daily newspapers Easily
With Difficulty
With Difficulty
Listening (please circle appropriate response)
 I am able to understand daily conversations Easily With Difficulty
 I am able to understand presentations and speeches Easily With Difficulty
Speaking (please circle appropriate response
 I am able to participate in simple conversations about the weather, family and transportation
Easily With Difficulty
 I am able to participate in conversations on current events and my professional areas
Easily With Difficulty
Other comments regarding your language proficiency:
11. Have you ever visited the U.S. Food and Drug Administration (FDA), National Institute of Health (NIH), or pharmaceutical companies/R&D Centers in the U.S. or participated in one of the programs the abovementioned institutions sponsored before? :
NO :
_________________________________________________________________________________________
YES :
_________________________________________________________________________________________
Please describe the program and your participation.
When did the program take place?
12. Have you ever visited Japan and had contact with any of the companies that are listed on our medical
Innovation tour? If yes, please describe the nature of your visit.
NO :
_________________________________________________________________________________________
YES :
_________________________________________________________________________________________
13. Have you ever seen the Facebook of the Japan Medical Innovation tour? If yes, please describe the impression.
NO :
_________________________________________________________________________________________
YES :
_________________________________________________________________________________________
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14 ． Achievement (i.e. List of Research, Publications, Awards). Please indicate any noteworthy achievements (both academic and personal) that show that you would be an asset to the program. Write the most recent achievements first.
15. On a separate sheet below in 300-500 words (roughly 1-2 double-spaced pages), please describe the following points. The number of letters will be observed strictly.
 Your areas of specialty and interest in specific medical research field and the area you would like to work on including your future career goals.
 Your motivation to participate in this program.
 Your personal thoughts on the current healthcare issues in Japan and the Asia.
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16. Emergency Contact Information
Name Relationship to Applicant
Postal Code County/Province/Prefecture
City Street
Phone Fax
E-mail Address
17. How did you learn about this program announcement?
□ ( At the university home page
)
□ (
Through the announcement circulated and/ posted on the bulletin board at your work place
)
□ （ Through the announcement posted on the relevant organizations and/or advertisement on the medical journals ）
（ if so, please tell us the name of the organization and/or the journal ）
＿＿ ( name of the organization, journal
)
□ (
Through introduction from your friends, supervisor, etc.
)
□ (
Other
)
18. On separate sheets, please include two letters of recommendation from professional or academic referees. The letters can be word processed but the signature of the referee must be visible meaning that the letter should be printed, signed by the referee and then scanned.
19. Signature
I certify that all of the statements made in this application are true, complete and correct to the best of my
( knowledge and belief and are made in good faith.
Signature of Applicant
) (
Date
)
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