PDF - 国際交流基金アジアセンター

The Japan Foundation Asia Center
Application Form for Asia Center Fellowship Program
Domestic
application
For use in FY 2014
For official use
事・大・総
Direct overseas
application
Date:
1. Applicant
(1) Name (*as shown in passport)
Family name
Given, Middle name
Family name
Given, Middle name
Name (in English)
Name
(in mother tongue)
Title
□Prof.
□Dr.
□Ms.
□Mr.
□Other（
）
(2) Date of birth / Sex / Nationality, etc.
Date of birth
(MM/DD/YY)
/
□Nationality □Citizenship
□Permanent residency
/
Sex
(Country)
(3) Residential address / Contact details
Postal code
Address
Country:
E-mail
(Tel)
Telephone/Fax
(Mobile)
(Fax)
(4) Current occupation
Institution/
Affiliation
Position
Postal code
Address
Country:
E-mail
(Tel)
Telephone/Fax
(Fax)
(1)
□Male
□Female
2. Personal history (Please attach a detailed C.V.)
(1) Academic history
Year of
Degree Issued
Degree
Institution
(2) Employment history
Year
Employment history
(3) Major achievements (Thesis, publications, productions, projects, etc.)
Year
Achievement history
(4) Membership in societies, organizations, etc.
(2)
Field of study
3. Record of activities overseas (List up to five main activities)
(Activity 1)
Period
Location
Activity
Details
(Activity 2)
Period
Location
Activity
Details
(Activity 3)
Period
Location
Activity
Details
(Activity 4)
Period
Location
Activity
Details
(Activity 5)
Period
Location
Activity
Details
(3)
4. Overview of project: (For items marked with an asteticks, please append details separately.)
(1) Project title
(2) Field
Field
Details
□Visual arts
(Painting, sculpture, photography, video,
film, design, craft, etc.)
□ Performing arts
(Theater, contemporary dance,
classical dance, music, etc.)
□ Cultural heritage, traditional culture
□ Cultural policy, arts management
□ Architecture
□ Sports
□ Media / Journalism
□ Civil society
(Philanthropy, NPO/NGO activities,
community activities, social
enterprise, etc.)
□ Humanities
(Literature, history, arts, cultural
anthropology, sociology, religious
studies, etc.)
□ Social sciences
(Political studies, economics,
sociology, international relations, etc.)
□ Other
(4)
(3) Summary of project (*Please also complete section 8. Contents of project (detailed).)
(4) Fellowship period
Period
(MM/DD/YY)
/
/
―
/
/
(No. of days:
)
(5) Schedule
From
(MM/DD/YY)
To
(MM/DD/YY)
Activities
(Please include host organization and/or collaborators)
City / Country
(6) Guarantors (*If consent has been granted for the acceptance of the applicant, please attach a copy of the letter of agreement.)
Country
Host organization / collaborators
Status
□ Consent granted
□ In negotiations
□ Consent granted
□ In negotiations
□ Consent granted
□ In negotiations
□ Consent granted
□ In negotiations
(5)
(7) English proficiency
Conversation
□Excellent
□Good
□Fair
□Poor
Reading
□Excellent
□Good
□Fair
□Poor
Writing
□Excellent
□Good
□Fair
□Poor
Proficiency tests
Type： □TOEFL
Score: (
□TOEIC
)
□IELTS
□Other (
)
(8) Japanese proficiency
Conversation
□Excellent
□Good
□Fair
□Poor
Reading
□Excellent
□Good
□Fair
□Poor
Writing
□Excellent
□Good
□Fair
□Poor
Proficiency tests
Type：
Score: (
□JLPT
□Other (
)
)
(9) Other languages
If other languages are necessary for your project, please input information about the language, your operational
capability in the language, and the status of your preparations.
Language
Current operational capability / status of preparations, etc.
5. References (*Please provide the names, affiliation, and contact information of your two referrers.)
(Referrer 1)
・Name:
・Institution:
・Position:
・E-mail:
・Tel:
(Referrer 2)
・Name:
・Institution:
・Position:
・E-mail:
・Tel:
(6)
6. Bibliography, case studies, etc. related to the project that you are applying for
7. Past fellowships awarded by the Japan Foundation (year, name of program, grant amount)
I certify that all the information provided in this application is true and correct.
Date_____________
_
(7)
Signature________________________
8. Contents of project (detailed)
Project title
*Please provide the following information.
(1) Background of project
(2) Objectives
(3) Contents
(4) Status of preparations
(5) Partners/collaborators
(6) Expected results
(7) Plans to publish/disseminate the results
(8) Plans for contributing to promoting cooperative and collaborative projects and to the building of networks/platforms in Asia
(8)
*8. Contents of project (detailed) Continued
*Please include a separate attachment where necessary.
(9)
<Attachments>
Please attach all of the following documents.
□ Personal history (C.V. of the applicant) (*Where necessary, please attach documents on past achievements.)
□ Letter of agreement from host organization/collaborators
□ Information (overview of the organization, C.V., etc.) and contact details about the host organization/collaborators
<Reference letter>
□ Reference letters (two letters)
*Please pass the attached template for the reference letter to your two referrers, and request that they send the letter to
the same recipient for your application form (that is, the Japan Foundation overseas office, Embassy of Japan, or the
headquarters of the Japan Foundation in Tokyo) by 1 December 2014.
(10)
推薦書 REFERENCE FORM
The Japan Foundation Asia Center Fellowship Program
下記申請者は国際交流基金・アジア・フェローシップを受け
ることを希望し、貴殿の推薦を得たいとしております。
The person named below wishes to apply for the Japan
Foundation Asia Center Fellowship Program. The applicant
would like you to write a letter of reference.
つきましては、申請者の当該プロジェクトに取り組む資格、
Please assess the applicant’s competence to carry out the
その成功の見込み、必要性及び重要性、貴殿と申請者の専門分 proposal as described, as well as the importance and impact of
the project, and describe the relationship between you and the
野におけるかかわり等について日本語又は英語でご記入の上、
applicant in the special field. Please send the original form to the
2014年12月1日必着で下記太線枠内の国際交流基金海外拠点、 Foundation overseas office or Japanese diplomatic mission
日本国大使館または直接国際交流基金東京本部に原本をご送 whose address appears below in the box outlined in bold lines, or
directly to the Foundation Headquarters in Tokyo. The deadline is
付ください。
December 1, 2014. The result of the screening will be announced
選考結果は2015年1月に本人に通知します。推薦者への結果 in January 2015 by the Foundation. Please note that the
Foundation does not inform referees/recommenders of the results
通知は行っておりませんので、予めご了承ください。
of screening.
〒160-0004
東京都新宿区四谷4-4-1
Tel: +81-3-5369-6025
国際交流基金アジアセンター
Fax: +81-3-5369-6036
The Japan Foundation Asia Center
4-4-1 Yotsuya, Shinjuku-ku, Tokyo 160-0004
Tel: +81-3-5369-6025
Fax: +81-3-5369-6036
以下の宛先に送付願います。Please send this form to the address as below.
□ 本部 /
Headquarters
□ 海外拠点・在外公館 [
]
The Japan Foundation overseas office or Japanese diplomatic mission [
住所 address [
氏名Name
申請者
Applicant
(Family name)
]
]
(First name)
所属機関
Institution
プロジェクト名
Project title
氏名Name
評価記入者
Referee/
Recommend
er
連絡先Contact information
現職Position
所属機関Institution
所見（本欄のみならず、署名済みの書類を添付いただいても結構です。
）Comments (You may either use this space or
attach a signed letter.)
注：太線枠内は申請者が記入のこと。Note: the applicant should fill in boxes outlined in bold lines.
日付Date
(11)
署名Signature
推薦書 REFERENCE FORM
The Japan Foundation Asia Center Fellowship Program
下記申請者は国際交流基金・アジア・フェローシップを受け
ることを希望し、貴殿の推薦を得たいとしております。
The person named below wishes to apply for the Japan
Foundation Asia Center Fellowship Program. The applicant
would like you to write a letter of reference.
つきましては、申請者の当該プロジェクトに取り組む資格、
Please assess the applicant’s competence to carry out the
その成功の見込み、必要性及び重要性、貴殿と申請者の専門分 proposal as described, as well as the importance and impact of
the project, and describe the relationship between you and the
野におけるかかわり等について日本語又は英語でご記入の上、
applicant in the special field. Please send the original form to the
2014年12月1日必着で下記太線枠内の国際交流基金海外拠点、 Foundation overseas office or Japanese diplomatic mission
日本国大使館または直接国際交流基金東京本部に原本をご送 whose address appears below in the box outlined in bold lines, or
directly to the Foundation Headquarters in Tokyo. The deadline is
付ください。
December 1, 2014. The result of the screening will be announced
選考結果は2015年1月に本人に通知します。推薦者への結果 in January 2015 by the Foundation. Please note that the
Foundation does not inform referees/recommenders of the results
通知は行っておりませんので、予めご了承ください。
of screening.
〒160-0004
東京都新宿区四谷4-4-1
Tel: +81-3-5369-6025
国際交流基金アジアセンター
Fax: +81-3-5369-6036
The Japan Foundation Asia Center
4-4-1 Yotsuya, Shinjuku-ku, Tokyo 160-0004
Tel: +81-3-5369-6025
Fax: +81-3-5369-6036
以下の宛先に送付願います。Please send this form to the address as below.
□ 本部 /
Headquarters
□ 海外拠点・在外公館 [
]
The Japan Foundation overseas office or Japanese diplomatic mission [
住所 address [
氏名Name
申請者
Applicant
(Family name)
]
]
(First name)
所属機関
Institution
プロジェクト名
Project title
氏名Name
評価記入者
Referee/
Recommend
er
連絡先Contact information
現職Position
所属機関Institution
所見（本欄のみならず、署名済みの書類を添付いただいても結構です。
）Comments (You may either use this space or
attach a signed letter.)
注：太線枠内は申請者が記入のこと。Note: the applicant should fill in boxes outlined in bold lines.
日付Date
(12)
署名Signature

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