NOT FOR SALE
Please carefully read the Application Guidance before completing this form.
Note:Type or handwrite clearly, and do not exceed the space provided for each section.

Deadline is
September 25, 2023 !!

(FOR OFFICE USE ONLY: Registration Number	)

The 24th Duskin Leadership Training in Japan
 A Program for Persons with Disabilities in Asia and the Pacific (2024)

Please answer the following questions, 
and attach your photo.

A photo must show your face and entire body. It must have been taken in the past 3 months.
If you are applying by post, please write your full name on the back of the photo.
If you are applying by email, please send your photo as a separate attachment.


1. Name
First (given) name(s) / Middle name / Second (family) name
Answer:

In your native language 
Answer:

In English alphabet
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2. Sex
1 Male
2 Female
3 Unspecified
Answer:



3. Date of Birth
Year/Month/Day
Answer:

Age(as of September 25, 2023)
Answer:



4. Contact details
1 Home
2 Office
3 Other (please specify)
Answer:

Postal address
Answer:

Country
Answer:

Telephone
Answer:

Fax
Answer:

Mobile phone
Answer:

Email
Answer:



5. Type of disability
1 Physical
2 Visual
3 Hearing
4 Intellectual
5 Mental
6 Other (please specify)
Answer:



6. Nationality
Answer:



7. Native language (mother tongue)
Answer:



8. Religion
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9. Marital status
1 Single
2 Married
Answer:



10. What do you do?
1 I am a student
2 I work
3 Other (please specify)
Answer:


If you are a student, please provide details of your institution

Name of your School/College/Institution
Answer:

Address
Answer:

Your school Year/Grade
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Your major
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When do you expect to graduate?
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If you have employment or any other kinds of work, please provide details below.

Your organization type
1 NGO
2 Public administration/government
3 Private firm/institution
4 Other type of institution
5 Self-employed
6 Family-run business
7 Freelance
8 Other (details)
Answer:

Name of Your Employer (Organization/Company)
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Address
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Telephone
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Fax
Answer:

Website
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Email
Answer:

Describe specialty of your organization and its main business
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Your status
1 Paid staff
2 Unpaid staff/Volunteer
3 Intern/Trainee
4 Other (details)
Answer:

Describe your job details including your present title
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11. Do you belong to any organization of/for persons with disabilities?
1 No, I donft belong to any organization.
2 Yes, I belong to the following organization.
Answer:


If your answer yes,Describe your organization infomation

Name of the organization
Answer:

Address
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Telephone	
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Website	
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Email
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Its purpose and activities:
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How are you affiliated with this organization?
1 Staff
2 Member
3 Volunteer
4 Service user
5 Other
Answer:

Describe your involvement
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12. Education
A. University/ School
Give the name of the institution from which you graduated, your degree/major and completion date. 
Please exclude information that you have already mentioned in Section 10.


Name 1
Answer:	
City/Country
Answer:	
Attended From (Month/Year)
Answer:	
Attended To (Month/Year)
Answer:	
Degree, Certificate or Diploma
Answer:	

Name 2
Answer:	
City/Country
Answer:	
Attended From (Month/Year)
Answer:	
Attended To (Month/Year)
Answer:	
Degree, Certificate or Diploma
Answer:	

Name 3
Answer:	
City/Country
Answer:	
Attended From (Month/Year)
Answer:	
Attended To (Month/Year)
Answer:	
Degree, Certificate or Diploma
Answer:	

Name 4
Answer:	
City/Country
Answer:	 
Attended From (Month/Year)
Answer:	
Attended To (Month/Year)
Answer:	
Degree, Certificate or Diploma
Answer:


B. Training/Seminar
List training courses and seminars etc. that you have attended and qualifications that you hold.

Name 1
Answer:
City/Country
Answer:	
training period(Month/Year)
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Certificates obtained
Answer:

Name 2
Answer:
City/Country
Answer:	
training period(Month/Year)
Answer:	
Certificates obtained
Answer:

Name 3
Answer:
City/Country
Answer:	
training period(Month/Year)
Answer:	
Certificates obtained
Answer:

Name 4
Answer:
City/Country
Answer:	
training period(Month/Year)
Answer:	
Certificates obtained
Answer:



13. Work Experience
Please exclude information that you have already mentioned in Section 10.

Name of employer 1
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
Answer:

Name of employer 2
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
Answer:

Name of employer 3
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
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Name of employer 4
Answer:
organization
Answer:
Description of organization
Answer:
period of employment (Month/Year)
Answer:
Title, duties and responsibilities
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14. Reason for applying : Why do you want to participate in this training program?
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15. Your training plan : What do you want to learn in Japan?
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16. Your future plan : What will you do after training?
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17. Your disability

What is the name of your disability?
Please describe details about your disability including medical records.
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Do you require any assistance in your daily life? 
1 YES
2 NO
Answer:

If YES, please answer all appropriate below

A. Aids
1 Electric Wheelchair
2 Manual Wheelchair
3 Crutches
4 Guide dog
5 White cane
6 Other (please specify)
Answer:


B. Personal Assistant
1 Full-time
2 Part-time
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C. What kind of assistance?
1 Mobility
2 Transferring
3 Eating
4 Cooking
5 Cleaning
6 Clothing
7 Toileting
8 Bathing
9 Other (please specify :)
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D. Give any additional information which would help us to understand your disability and condition
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18. Do you have a dietary, medical or any other restriction in your daily life due to your religion or health condition?
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19. Describe your personal history.
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20. What are your hobbies and interests?
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21. Have you traveled abroad before? 
Give details of any travel experience abroad (e.g., study, training and holidays), including its destination, duration and purpose.
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22. How did you learn about this program and where did you get this application form?
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23. Your language skills   
Please answer number that indicates your level on each section.

A. ENGLISH

Speaking 
1 None
2 Basic communication
3 Everyday conversation 
4 Business level
5 Native level
Answer:

Listening
1 None
2 Basic communication
3 Everyday conversation
4 Business level
5 Native level
Answer:

Reading 
1 None
2 Some words
3 Simple sentences
3 Short stories	
4 Newspapers
Answer:

Writing
1 None
2 Some words
3 Simple sentences
4 Short essays
5 Business
6 reports
Answer:


B. JAPANESE

Speaking
1 None
2 Greetings
3 Basic communication
4 Everyday conversation
5 Business level
Answer:

Listening
1 None
2 Greetings
3 Basic communication
4 Everyday conversation
5 Business level
Answer:

Reading
1 None
2 Some letters
3 Simple sentences
4 Short stories	
5 Newspapers 
Answer:

Writing
1 None
2 Some letters
3 Simple sentences
4 Short essays
5 Business reports
Answer:


C. Do you use or understand any of the followings?

Braille
1 Native language(please specify)
2 English (please tell us the Grade)
3 Japanese
4 Other (please specify)
Answer:


Sign language
1 Native language(please specify)
2 ASL
3 International
4 Japanese
5 Other (please specify)
Answer:


Lip-reading
1 Native language(please specify)
2 English
3 Japanese
4 Other(please specify)
Answer:


D. If you have any other communication skills, please describe below :
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24. Referee information   Give the name and contact details of your referee.

Name
Answer:

Relationship to you
Answer:

Address
Answer:

Occupation
Answer:

Email
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Telephone
Answer:

Mobile phone:
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25. Surety information   Give the name and contact details of your surety.

Name 
Answer:

Relationship to you
Answer:

Address
Answer:

Occupation
Answer:

Email
Answer:

Telephone
Answer:

Mobile phone:
Answer:



26. Who completed this application form?
1 I completed this form by myself.
2 I got help (please give details on the person who completed this form on behalf of you.)
Answer:


If 2, please answer the following questions

Name
Answer:

Relationship to you
Answer:

Reason for assistance:   		
Answer:



27. Have you applied for this program before?
1 Yes, I applied (What was the year you applied?)	
2 No, this is my first time applying.
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28. Declaration statement by the applicant

gI hereby certify that all the information stated above is true, correct and complete.h

Your signature (type your name)


Date
Answer:


The end of the form.