Title:
Mr
Ms
Mrs
_______
Family name:
Given name:
Address:
Post code / City:
Country:
Please choose your country!
Andorra
United Arab Emirates
Afghanistan
Antigua and Barbuda
Anguilla
Albania
Armenia
Netherlands Antilles
Angola
Antarctica
Argentina
American Samoa
Austria
Australia
Aruba
Azerbaijan
Bosnia and Herzegovina
Barbados
Bangladesh
Belgium
Burkina Faso
Bulgaria
Bahrain
Burundi
Benin
Bermuda
Brunei Darussalam
Bolivia
Brazil
Bahama
Bhutan
Burma (no longer exists)
Bouvet Island
Botswana
Belarus
Belize
Canada
Cocos (Keeling) Islands
Central African Republic
Congo
Switzerland
C�te Divoire (Ivory Coast)
Cook Iislands
Chile
Cameroon
China
Colombia
Costa Rica
Cuba
Cape Verde
Christmas Island
Cyprus
Czech Republic
Germany
Djibouti
Denmark
Dominica
Dominican Republic
Algeria
Ecuador
Estonia
Egypt
Western Sahara
Eritrea
Spain
Ethiopia
Finland
Fiji
Falkland Islands (Malvinas)
Micronesia
Faroe Islands
France
France, Metropolitan
Gabon
United Kingdom (Great Britain)
Grenada
Georgia
French Guiana
Ghana
Gibraltar
Greenland
Gambia
Guinea
Guadeloupe
Equatorial Guinea
Greece
South Georgia and the South Sandwich Islands
Guatemala
Guam
Guinea-Bissau
Guyana
Hong Kong
Heard & McDonald Islands
Honduras
Croatia
Haiti
Hungary
Indonesia
Ireland
Israel
India
British Indian Ocean Territory
Iraq
Islamic Republic of Iran
Iceland
Italy
Jamaica
Jordan
Japan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Comoros
St. Kitts and Nevis
Korea, Democratic Peoples Republic of
Korea, Republic of
Kuwait
Cayman Islands
Kazakhstan
Lao Peoples Democratic Republic
Lebanon
Saint Lucia
Liechtenstein
Sri Lanka
Liberia
Lesotho
Lithuania
Luxembourg
Latvia
Libyan Arab Jamahiriya
Morocco
Monaco
Moldova, Republic of
Madagascar
Marshall Islands
Mali
Mongolia
Myanmar
Macau
Northern Mariana Islands
Martinique
Mauritania
Monserrat
Malta
Mauritius
Maldives
Malawi
Mexico
Malaysia
Mozambique
Namibia
New Caledonia
Niger
Norfolk Island
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
Niue
New Zealand
Oman
Panama
Peru
French Polynesia
Papua New Guinea
Philippines
Pakistan
Poland
St. Pierre & Miquelon
Pitcairn
Puerto Rico
Portugal
Palau
Paraguay
Qatar
R�union
Romania
Russian Federation
Rwanda
Saudi Arabia
Solomon Islands
Seychelles
Sudan
Sweden
Singapore
St. Helena
Slovenia
Svalbard & Jan Mayen Islands
Slovakia
Sierra Leone
San Marino
Senegal
Somalia
Suriname
Sao Tome & Principe
El Salvador
Syrian Arab Republic
Swaziland
Turks & Caicos Islands
Chad
French Southern Territories
Togo
Thailand
Tajikistan
Tokelau
Turkmenistan
Tunisia
Tonga
East Timor
Turkey
Trinidad & Tobago
Tuvalu
Taiwan, Province of China
Tanzania, United Republic of
Ukraine
Uganda
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vatican City State (Holy See)
St. Vincent & the Grenadines
Venezuela
British Virgin Islands
United States Virgin Islands
Viet Nam
Vanuatu
Wallis & Futuna Islands
Samoa
Yemen
Mayotte
Yugoslavia
South Africa
Zambia
Zaire
Zimbabwe
Unknown or unspecified country
_______________________________
E-mail:
Phone:
Date of birth:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
Nationality:
Please choose your nationality!
Andorra
United Arab Emirates
Afghanistan
Antigua and Barbuda
Anguilla
Albania
Armenia
Netherlands Antilles
Angola
Antarctica
Argentina
American Samoa
Austria
Australia
Aruba
Azerbaijan
Bosnia and Herzegovina
Barbados
Bangladesh
Belgium
Burkina Faso
Bulgaria
Bahrain
Burundi
Benin
Bermuda
Brunei Darussalam
Bolivia
Brazil
Bahama
Bhutan
Burma (no longer exists)
Bouvet Island
Botswana
Belarus
Belize
Canada
Cocos (Keeling) Islands
Central African Republic
Congo
Switzerland
C�te Divoire (Ivory Coast)
Cook Iislands
Chile
Cameroon
China
Colombia
Costa Rica
Cuba
Cape Verde
Christmas Island
Cyprus
Czech Republic
Germany
Djibouti
Denmark
Dominica
Dominican Republic
Algeria
Ecuador
Estonia
Egypt
Western Sahara
Eritrea
Spain
Ethiopia
Finland
Fiji
Falkland Islands (Malvinas)
Micronesia
Faroe Islands
France
France, Metropolitan
Gabon
United Kingdom (Great Britain)
Grenada
Georgia
French Guiana
Ghana
Gibraltar
Greenland
Gambia
Guinea
Guadeloupe
Equatorial Guinea
Greece
South Georgia and the South Sandwich Islands
Guatemala
Guam
Guinea-Bissau
Guyana
Hong Kong
Heard & McDonald Islands
Honduras
Croatia
Haiti
Hungary
Indonesia
Ireland
Israel
India
British Indian Ocean Territory
Iraq
Islamic Republic of Iran
Iceland
Italy
Jamaica
Jordan
Japan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Comoros
St. Kitts and Nevis
Korea, Democratic Peoples Republic of
Korea, Republic of
Kuwait
Cayman Islands
Kazakhstan
Lao Peoples Democratic Republic
Lebanon
Saint Lucia
Liechtenstein
Sri Lanka
Liberia
Lesotho
Lithuania
Luxembourg
Latvia
Libyan Arab Jamahiriya
Morocco
Monaco
Moldova, Republic of
Madagascar
Marshall Islands
Mali
Mongolia
Myanmar
Macau
Northern Mariana Islands
Martinique
Mauritania
Monserrat
Malta
Mauritius
Maldives
Malawi
Mexico
Malaysia
Mozambique
Namibia
New Caledonia
Niger
Norfolk Island
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
Niue
New Zealand
Oman
Panama
Peru
French Polynesia
Papua New Guinea
Philippines
Pakistan
Poland
St. Pierre & Miquelon
Pitcairn
Puerto Rico
Portugal
Palau
Paraguay
Qatar
R�union
Romania
Russian Federation
Rwanda
Saudi Arabia
Solomon Islands
Seychelles
Sudan
Sweden
Singapore
St. Helena
Slovenia
Svalbard & Jan Mayen Islands
Slovakia
Sierra Leone
San Marino
Senegal
Somalia
Suriname
Sao Tome & Principe
El Salvador
Syrian Arab Republic
Swaziland
Turks & Caicos Islands
Chad
French Southern Territories
Togo
Thailand
Tajikistan
Tokelau
Turkmenistan
Tunisia
Tonga
East Timor
Turkey
Trinidad & Tobago
Tuvalu
Taiwan, Province of China
Tanzania, United Republic of
Ukraine
Uganda
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vatican City State (Holy See)
St. Vincent & the Grenadines
Venezuela
British Virgin Islands
United States Virgin Islands
Viet Nam
Vanuatu
Wallis & Futuna Islands
Samoa
Yemen
Mayotte
Yugoslavia
South Africa
Zambia
Zaire
Zimbabwe
Unknown or unspecified country
_______________________________
Native Language:
Please choose your mother language!
French
Russian
Italian
German
English
Spanish
others
Swedish
Danish
Norwegian
Dutch
_______________________________
Other Languages:
Profession:
Please choose your profession!
Student
Self employed
Office Worker
Other
_______________________________
Course Information
Course:
Please choose your course!
20 Group lessons a week
30 Group lessons a week
20 Group lessons and 5 Private lessons
20 Group lessons and 10 Private lessons
_______________________________
Course Start:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Course End:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Duration in weeks:
How many weeks?
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
9 weeks
10 weeks
11 weeks
12 weeks
_______________________________
Japanese Language Level
Please choose your level
Beginner Level
Elementary Level
First Intermediate Level
Intermediate Level
Upper Level
_______________________________
Internships
in Japan, Fukuoka
Internship Type:
Your type of your internship
Trial Internship (1 day)
Short Internship (1-4 weeks)
Long Internship (1-6 months)
_______________________________
Internship:
Please choose your internship!
Art / Craft
IT
Fashion
NPO
Welfare
Tourism
Sales/Trade
Sports
Hotel / Restaurants
Education / Languages
Production
Eating and drinking business
Media
_______________________________
Course Start:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Course End:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Duration:
How long is your internship?
1 day
1 week
2 weeks
3 weeks
4 weeks
1 month
2 months
3 months
4 months
5 months
6 months
_______________________________
Japanese Language Level
Please choose your level
Beginner Level
Elementary Level
First Intermediate Level
Intermediate Level
Upper Level
_______________________________
Previous stay in
Japan:
How many times did you visit Japan?
First time
One time
More than two times
_______________________________
Accommodation
Accommodation Type:
Choose your desired accommodation type!
Host family
Flat share
Not Neccessary
_______________________________
Accommodation Start
date:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Accommodation End date:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Duration in weeks:
How many weeks?
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 weeks
8 weeks
9 weeks
10 weeks
11 weeks
12 weeks
_______________________________
Smoker
Are you a smoker?
Non smoker
Smoker
_______________________________
Vegetarian:
Are you a vegetarian?
Vegetarian
Non vegetarian
_______________________________
Host with children:
Host family with children?
I want a host family with children
I do not mind.
No host family with children.
_______________________________
Single person:
Single Person?
It does not matter.
No single person!
_______________________________
Hosts with dogs:
Do you mind a host family with a dog?
It does not matter.
No dogs!
_______________________________
Hosts with cats
Do you mind a host family with a cat?
Does not matter
No cats!
_______________________________
Allergies /
Medical conditions:
Requests / Remarks:
Leisure
Transfer
Transfer required
Please choose your transfer
From airport to accommodation
From accommodation to airport
Round transfer
Not needed!
_______________________________
Arrival date:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Arrival time:
Flight number::
Departure date:
day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
19
20
21
22
23
24
25
26
27
28
29
30
31
____
month
January
February
March
April
May
June
July
August
September
October
November
December
_________
year
2008
2009
2010
2011
_____
Departure time:
Comments /
Questions :