form5dan6tahun2012

7/29/2019 Form5dan6Tahun2012

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NATIONAL BOARD FOR THE PLACEMENT AND PROTECTIONINDONESIAN OVERSEAS WORKERS

Jl. MT. Haryono Kav. 52 Jakarta Selatan-17220, Lt. 5,Telp./Fax. : 021-7901158

Form 6

Information Sheet of Applicants for IndonesianCandidate for Kaigofukushishi

Name __________________________________________ Sex ___________(Note) Fill in your name in print, as written on passport

Date of birth _____________________________________ Age ___________

Address_______________________________________________________

Telephone number______________________________________________

Spouse/Dependent childrenNumber of dependent children: _____Marital Status (Married : Single); Responsible to support your spouse (Yes : No)

(passport holder only)Passport number _________________________Date of expiration (Year/Month/Day) _______________________

Education : (if any, most recent first)

From(year)

To (year) Nursing School/University(Name, Place)

Degree Obtained

Work experience __________________________________________________________

Japanese Langguage ProficiencyLevel of Japanese Language Proficiency Test conducted by the Japan Foundation or JapanEducational Exchanges and Services ( if any ) : ______Number of years of studying Japanese (if any, most recent first)

From(year) To (year) Japanese Language Institution Country

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Request to accepting institution (if any)(ex. I need to take medicine three times a day, I want to cook by myself because Im allergic, I want to have days off on fixeddays of week, I want to go back to may home country temporarily around new years day etc.)

_______________________________________________________________________________

Other descriptions (English language proficiency, qualification, etc.)

________________________________________________________________________

Preference of the facility :Urban area Local area

RegionHokkaido ______ Tohoku _____ Kanto ______ Hokuriku-Shinetsu ______ Tokai _____

Kinki _____ Chugoku ______ Shikoku _____ Kyushu-Okinawa _____No Preference_________

Prefecture __________________________________Specialization _______________________________Holidays ___________________________________Others ____________________________________

Declaration of authenticity of the abovementioned items______(Signature)______Endorsement by the National Board of the abovementioned duly authenticated documents

________(Signature)_____________

Note 1 This form is for Applicants for Indonesian Candidate of Kaigofukushishi.Note 2 Certicate of academic record of college should be attached.Note 3 Those who are qualified nurses registered under the laws and regulations of Indonesia

should attach Certificate of Registration of Nurse.Note 4 Fill this form for all applicants and gather.Note 5 Documents to certify Japanese language ability, for example, certificates of the

Japanese-Language Proficiency Test (Level 1 or 2) should be attached if you wish tobe exempted from Japanese language training in Japan.


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NATIONAL BOARD FOR THE PLACEMENT AND PROTECTIONINDONESIAN OVERSEAS WORKERS

Jl. MT. Haryono Kav. 52 Jakarta Selatan-17220, Lt. 5,Telp./Fax. : 021-7901158

Form 5

Information Sheet of Applicants for IndonesianCandidate for Kangoshi

Name __________________________________________ Sex __________(Note) Fill in your name in print, as written on passport

Date of birth _____________________________________ Age ___________

Address _______________________________________________________

Telephone number______________________________________________

Spouse/Dependent childrenNumber of dependent children: __________Marital Status (Married : Single); Responsible to support your spouse (Yes : No

(passport holder only)Passport number _________________________Date of expiration (Year/Month/Day) _______________________

Education : (most recent first)

From (year) To (year) Nursing School/University(Name, Place)

DegreeObtained

Number of certificate for qualified nurse in Indonesia and the date of obtaining the certificate________________________________________________________________________

Total number of years and months of experience as a nurse ____ years and ____ months

1. Name of hospital ________________________________________Characteristics of ward _____

Number of beds ______Number of years and months of work ______2. Name of hospital ________________________________________

Characteristics of ward _____Number of beds ______Number of years and months of work ______

3. Name of hospital ________________________________________Characteristics of ward _____Number of beds _______Number of years and months of work ______(Note: Fill in from the recent experience)

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Japanese Langguage ProficiencyLevel of Japanese Language Proficiency Test conducted by the Japan Foundation or Japan

Educational Exchanges and Services ( if any ) : ________Number of years of studying Japanese (if any, most recent first)

From (year) To (year) Japanese Language Institution Country

Request to accepting institution (if any)(ex. I need to take medicine three times a day, I want to cook by myself because Im allergic, I want to have days off on fixeddays of week, I want to go back to may home country temporarily around new years day etc.)

________________________________________________________________________

Other descriptions (English language proficiency, qualification, etc.)

________________________________________________________________________

Preference of the facility :Urban area Local area

RegionHokkaido ______ Tohoku _____ Kanto ______ Hokuriku-Shinetsu ______ Tokai_____Kinki _____ Chugoku ______ Shikoku _____ Kyushu-Okinawa _____No Preference _________

Prefecture __________________________________Specialization _______________________________Holidays ___________________________________Others ____________________________________

Declaration of authenticity of the abovementioned items _________(Signature)________Endorsement by the National Board of the abovementioned duly authenticated documents

________(Signature)___________

Note 1 This form should be used for Applicants for Indonesian Candidates for Kangoshi.

Note 2 Certificate of academic record of nursing college should be attached.Note 3 Certificate of graduation of nursing school/college should be attached.Note 4 Certificate of Registration of Nurse should be attached.Note 5 Certificate of employment record should be attachedNote 6 Fill this form for all applicants and gather.Note 7 Documents to certify Japanese language ability, for example, certificates of the

Japanese-Language Proficiency Test (Level 1 or 2) should be attached if you wish tobe exempted from Japanese language training in Japan.