≪Young Leaders Training Course / 青年研修≫

CONFIDENTIAL
Application Guideline for
the JICA Knowledge Co-Creation Program（Young Leaders）

This guideline explains how to apply for the Knowledge Co-Creation Program (KCCP) (Young
Leaders) of the Japan International Cooperation Agency (JICA) under the Official
Development Assistance Program of the Government of Japan.
Please complete the Application Forms according to the guideline. For additional information,
please consult the JICA Office, or in its absence, the Embassy of Japan in your country.

Forms to be submitted
Form1. Application Form
Form2. Questionnaire on Medical Status and Restrictions
Form3. Contact Person at Your Organization
for Post-program Survey about KCCP for Young Leaders
Form4. Terms and Conditions, and Declaration

Please be advised:
(a) To carefully read the General Information (GI) of the KCCP,
(b) To fill only in typewritten except for signature,
(c) To fill in the form in English,
(d) To use “√” or “x” to mark the ( ) options,
(e) To attach your photographs,
(f) To prepare document(s) described in the GI and/or confer with the JICA Expert or JICA
overseas office, and attach these documents to the completed Application Forms,

In submitting the Application Forms and attached documents, please make sure:
(g) To prepare a copy of your passport,
(h) To confirm the application procedure stipulated by your government,
(i) To submit the original Application Forms and all necessary document(s) to the
responsible organization of your government according to its application procedure, and
(j) That your participation may be denied, if you fail to provide all required information and
documents completely and on time.

1
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
CHECK LIST before submission:

Items Form No. Check

1. Fill in all items in typewritten All the forms
2. Your signature Form 1, 2, 4
3. Your Photo Form 1
4. Attach a copy of passport (Machine Readable Zone) -
* Applicants from Latin American and the Caribbean Countries,
please refer to the note below.
5. Attach the required document(s) as instructed in the GI -

Note for Applicants from Latin American and the Caribbean Countries:
(1) If you are from any of the countries listed below and have a passport with a valid U.S. visa,
please attach herewith a copy of Identification Pages on the inside cover of your passport
(i.e. the two pages that include your photograph and detailed passport information), and the
page of U.S. visa:

Antigua and Barbuda, Argentina (only Japanese descendants), Barbados, Bolivia,

Brazil, Chile, Colombia, Dominica, Ecuador, Grenada, Guatemala, Guyana, Haiti,
Mexico, Peru, Rep. of Dominica, St. Christopher and Nevis, St. Lucia, St. Vincent and
the Grenadines, Suriname, or Venezuela.

(2) If you are from any of countries listed below and have a passport without a valid U.S. visa,
please attach herewith a copy of Identification Pages on the inside cover of your passport
(i.e. the two pages that include your photograph and your detailed passport information).

Belize, Costa Rica, El Salvador, Honduras, Jamaica, Marshall, Micronesia, Nicaragua,

Palau, Panama, Paraguay, Trinidad and Tobago, and Uruguay.

2
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
Application Form for the JICA Knowledge Co-Creation Program (Young Leaders):

Form1. APPLICATION FORM

*To be signed by your supervisor (the head of the relevant department / division of your organization).
INSTITUTION/DIVISION (Approval Sign & Stamp from Director)
Our organization hereby applies for Knowledge Co-Creation program (KCCP) for Young
Leaders of the Japan International Cooperation Agency and proposes to dispatch
qualified nominees to participate in the programs.

Date: Signature:
Name:
Title / Position
Official
Department / Division
Stamp
Office Address and Address:

Contact Information Tel: E-mail: Fax:

MINISTRY (When this application is through a ministry.)

Our ministry hereby applies for Knowledge Co-Creation program (KCCP) for Young
Leaders of the Japan International Cooperation Agency and proposes to dispatch
qualified nominees to participate in the programs.

Date: Signature:
Name:
Title / Position Official Stamp
Department / Division

MINISTRY OF STATE SECRETARIAT

I have examined the documents in this form and found them true. Accordingly, I agree to
nominate this person(s) on behalf of our government.

Date: Signature:
Name:
Title / Position Official Stamp
Department / Division

3
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
※To be filled by Applicant.

1. Course Title: (as shown in the GI)

Attach here
your photo

(taken within
2. Course Number: (the number as “xxxxxxxxxJxxx“ shown in the GI) the last six months)

Size: 4.5x3.5cm

3. Personal Information on Applicant

1) Name of Applicant (as shown in the passport)

*Please type the name as shown in the passport carried. The information will be used for flight
arrangements.

Family Name / Surname

First Name

Middle Name

2) Nationality
(as shown in the passport)

3) Sex ( ) Male ( ) Female

Age
Month
Date Year (as of the date of
(ex. April)
4) Date of Birth the form)

5) Passport/Visa
Passport possession ( ) Yes ( )No Expiry date Date Month Year
of passport
USA visa possession* ( ) Yes ( )No

*Applicants from Latin America and the Caribbean only.

4
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
6) Contact Information
Address:
Private TEL*: Mobile*:
FAX*: E-mail:
Address:
Office TEL*: Mobile*:
FAX*: E-mail:
Name:
Relationship to you:
Emergency
Address:
Contact
TEL*: Mobile*:
FAX*: E-mail:
* Please fill it out from country code for telephone, mobile, and fax number.

7) Present Position

Organization

Year that entered

the organization

Department / Division

Title

From
No. of years of Years
(Month/Year)
service in the present
position

( ) National Government ( ) Local Government ( ) Public Enterprise

( ) Private (profit) ( ) NGO/Private (Non-profit) ( ) University
Type of Organization
( ) Other ：

Number of employees

Home Page Address

【Questionnaire on Relationship with the Military】

*If your organization and/or your status is related to the Military, please mark with ✓ or X below in
the ( ) which best describes the relationship.

( ) the Military, an active military personnel or a military personnel listed in the muster roll/military register
( ) an organization affiliated with the Military, or a personnel who does not belong to the military at present
but is listed in the muster roll/military register
( ) the Department or the Ministry of Defense, an organization affiliated with the Ministry of Defense, or staff
of the Ministry of Defense
( ) a civilian organization but with military personnel or a military division within the organization

5
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
( ) an organization which will be affiliated with or under the control of the Military in times of emergency as
specified clearly in its organic law/law of establishment

4. Experience and Eligibility

1) Career Background (After graduation and before taking the present position)
Period
City/ Position or Title and
Organization From To Brief Job Description
Country Department/Division
Month/Year Month/Year

2) Academic Background (University, College or Higher Education)

Period
City/
Institution From To Degree Major
Country
Month/Year Month/Year

3) Experience of Training or Study in Foreign Countries (including all the training

experiences in JICA’s programs)
Period
City/
Institution From To Field of Study / Program Title
Country
Month/Year Month/Year

4) Experience visiting / living in Japan

( ) Yes ( ) One month or less ( ) More than one month
( ) No

5) Language Proficiency (Self-Assessment)

1) Language to be used in the course (as in the GI)

Listening ( ) Excellent ( ) Good ( ) Fair ( ) Poor

6
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
Speaking ( ) Excellent ( ) Good ( ) Fair ( ) Poor

Reading ( ) Excellent ( ) Good ( ) Fair ( ) Poor

Writing ( ) Excellent ( ) Good ( ) Fair ( ) Poor

Language Tests Scores if any

(ex. TOEFL, TOEIC, etc.)

2) Mother Tongue

3) Other languages
( ) Excellent ( ) Good ( ) Fair ( ) Poor
( )

Refined fluency skills and topic-controlled discussions, debates & presentations. Formulates strategies to
Excellent
deal with various essay types, including narrative, comparison, cause-effect & argumentative essays.

Conversational accuracy & fluency in a wide range of situations: discussions, short presentations &
Good
interviews. Compound complex sentences. Extended essay formation.

Broader range of language related to expressing opinions, giving advice, making suggestions. Limited
Fair
compound and complex sentences & expanded paragraph formation.

Simple conversation level, such as self-introduction, brief question & answer using the present and past
Poor
tenses.

5. Background and Purpose of application (to be completed by the Applicant)

1) Personal Statement including your Goal: Describe the reasons for your application and what you intend to
achieve in this program.

2) Relevant Experience of Applicant: Describe previous occupational experiences which are highly relevant to the
themes of this program.

3) Area of Interest and/or your expectation: Specify your particular interest with reference to the contents of
this program.

7
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL

By Applicant
Date

Name

Signature

8
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
Application Form for the JICA Knowledge Co-Creation Program (Young Leaders)

Form 2. QUESTIONNAIRE ON MEDICAL STATUS AND RESTRICTIONS

(Self-Declaration)
1. Present Medical Status
(a) Have you taken any medicine or had a medical checkup by a physician for any
illness such as diabetes, hypertension, asthma, etc.?
[ ] No [ ] Yes:
Name of illness ( ), Name of medicine ( )
If yes, please attach your doctor's letter (preferably in English) that describes
the current status of your illness, and gives agreement to your participation in
the program.
(c) Do you have any allergies to the medicine, food, pollen etc.?
[ ] No [ ] Yes:
What are you allergic to? What kind of allergic symptoms do you have such
as itch, rash, hives, etc.?
( )
(d) Please indicate any needs arising from disabilities which may require additional support
and facilities.
( )
Note: Disability will not lead to exclusion of the Applicant from the program. However, the Applicant may
be inquired directly by the JICA official in charge for a more detailed account of his/her condition.

2. Medical History
(a) Have you had any illness such as heart, hepatic, kidney disease, etc.?
[ ] No [ ] Yes:
Please specify ( )
(b) Have you or/and your family members had tuberculosis?
[ ] No [ ] Yes:
Please specify ( )
(c) Have you ever been a patient in a mental clinic or been treated by a psychiatrist?
[ ] No [ ] Yes:
Please specify ( )
(d) Have you ever had any sleeping, eating or other disorders?
[ ] No [ ] Yes:
Please specify ( )
name of medicine taken if any ( )

9
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
3. Other Medical Issues/Conditions
If you have any medical issues/conditions that are not described above, please indicate
below.

* Are you pregnant?

[ ] No [ ] Yes:
Weeks of pregnancy ( weeks)

I certify that I have read the above instructions and answered all questions truthfully and
completely to the best of my knowledge.
I understand and accept that medical conditions resulting from an undisclosed pre-existing
condition may not be financially compensated by JICA, and may result in termination of the
program.
I understand and accept that this questionnaire will be checked for my health care by the
people who are engaged in the program during my stay in Japan.

By Applicant
Date

Name

Signature

※Please notify JICA staff upon any changes in your health condition after
submission of the form.

10
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
Application Forms for the JICA Knowledge Co-Creation Program (Young Leaders)

Form3. CONTACT PERSON AT YOUR ORGANIZATION

FOR POST-PROGRAM SURVEY
ABOUT KCCP FOR YOUNG LEADERS

JICA conducts ex-post questionnaire surveys on Participants of the KCCP for Young
Leaders in order to understand how Participants utilize the knowledge acquired in Japan
in their daily work. For this purpose, JICA would like to send Participants a questionnaire
by e-mail after the program.
In addition, considering the purpose of the survey, we also would like to send the
questionnaire to persons other than the Participants such as their supervisor or the
person in the human resources department, who can observe changes in Participants’
attitude in performing his/her tasks after the program.
We would highly appreciate it if you could give us the name to whom JICA can send the
questionnaire(s). Please fill in the following tables. The questionnaire(s) will be directly
sent by e-mail to the Applicant and the person given below within 1 year after the program.
We kindly ask for your understanding and cooperation for implementing the survey.

【Name of Applicant】
Name

【Contact Person at Applicant’s organization】 (Applicant’s supervisor or a

person in the human resources department to whom JICA can send the
questionnaire after the program)】

Name

Designation / Position

Department / Division

E-mail Address

11
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
Application Forms for the JICA Knowledge Co-Creation Program (Young Leaders)

Form4. TERMS AND CONDITIONS

1. General Rules

The participants are requested:

(1) to strictly observe the course schedule,
(2) not to change the air ticket (and flight class and flight schedule arranged by JICA ) and
lodging by the participants themselves,
(3) to understand that leaving Japan during the course period (to return to home country,
etc.) is not allowed (except for programs longer than one year),
(4) not to bring or invite any family members (except for programs longer than one year),
(5) to carry out such instructions and abide by such conditions as may be stipulated by both
the nominating Government and the Japanese Government in respect to the course,
(6) to observe the rules and regulations of the program implementing partners to provide
the program or establishments,
(7) not to engage in political activities, or any form of employment for profit,
(8) not to quit the program, should the participants violate Japanese laws and JICA’s
regulations, or the participants commit illegal or immoral conduct, or get critical illness
or seriously injury and be considered unable to continue the course,
(9) to return the total amount or a part of the expenditure for the KCCP depending on the
severity of such violation, should the participants violate the laws and ordinances,
(10) not to drive a car or motorbike, regardless of an international driving license possessed,
(11) to observe the rules and regulations at the place of the participants’ accommodation,
and
(12) to refund allowances or other benefits paid by JICA in the case of a change in schedule.

2. Privacy Policy

The participants are requested to understand Privacy Policy of JICA as follows.

(1) Scope of Use

Any information used for identifying individuals that is acquired by JICA will be stored, used,
or analyzed only within the scope of JICA activities. JICA reserves the right to use such
identifying information and other materials in accordance with the provisions of this Privacy
Policy.
(2) Limitations on Use and Provision
JICA shall never intentionally provide information to a third party that can be used to identify
individuals, with the following three exceptions:
(a) legally mandated disclosure requests;
(b) the information provider grants permission for information disclosure to a third party;
(c) JICA commissions a party to process information collected, in which case the
information provided will be within the scope of commissioned tasks.
(3) Security Notice
12
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
JICA takes measures required to prevent leakage, loss, or destruction of acquired
information, and to otherwise properly manage such information.

*Information Security Policy of JICA in relation to Personal Information Protection

■ JICA will properly and safely manage personal information collected through
Application Forms in accordance with JICA’s Privacy Policy and the relevant laws
of Japan concerning protection of personal information and take protection
measures to prevent divulgation, loss or damages of such personal information.

■ Unless otherwise obtained approval from the Applicant him/herself or there are
valid reasons such as disclosure under the laws and ordinances, etc. and except
for the reasons in 1-3 below, JICA will neither provide nor disclose personal
information to any third party. JICA will use personal information provided only for
the purposes in 1-3 below and will not use the information for any purposes other
than those described in 1-3 below without prior approval of the Applicant
him/herself.

1. To provide the KCCP to Participants.

2. To provide the KCCP to Participants under the Citizens’ Cooperation Activities.
3. In addition to 1 and 2 above, when the government of Japan or JICA determines it
necessary in technical cooperation.

※JICA’s policy for the transfer of personal data from the European Economic Area（EEA） to outside the
EEA (to Japan and third countries);
JICA has revised “Bylaws for the Implementation of Personal Information Protection” which was published
based on Japan’s legislation by adding new provisions regarding how to deal with personal data within the
EEA in order to meet General Data Protection Regulations (GDPR’s) requirements for data protection.
Based on the new bylaws, JICA entered into the EU Standard Contractual Clauses (SCCs) which allows
us to transfer personal data from offices within the EEA to offices outside the EEA (in Japan and third
countries).

3. Copyright Policy
The participants are requested to comply with the following;

1. The participants shall use all the documents provided for the KCCP (including texts,
materials, and etc.), within the scope approved by each copyright holder.
If the participants apply to online KCCP, the participants shall also comply with terms of
use of copyrighted works for the online KCCP that are shown on the JICA website.
(https://www.jica.go.jp/english/our_work/types_of_assistance/tech/acceptance/training/i
ndex.html)

2. All the documents for the KCCP (including reports, action plans, presentations, and etc.)
shall be prepared by the participants themselves in principle. If the participants use a
third party’s work (reproduction, photograph, illustration, map, figures, etc.), which is
protected under the laws and regulations in the participants’ country or copyright-related
multinational agreements, the participants shall obtain a license to use the work within
the scope approved by the copyright holder.
13
 ≪Young Leaders Training Course / 青年研修≫
CONFIDENTIAL
3. The participants shall agree that JICA may use the documents prepared by the
participants (including but not limited to reproduction, public transmission, distribution
and modification) for other programs conducted by JICA (for example, as references for
other KCCP courses and project formulation).

4. Portrait Right Policy

During the implementation period of KCCP, JICA (including hired photographer and program
implementing partners) will shoot photographs and video footage mainly for the following
purposes:
・ Use on the website or in SNS administrated/operated by JICA,
・ Use in JICA publications (public relations magazines, annual reports, journals, etc.) in
printed or electronic form,
*Photos and images taken will not be used for commercial purposes and the participants’
personal information will not be disclosed to any third party without the consent of the
participants.

JICA would appreciate it if the participants of KCCP grant the participants themselves portrait
right license to JICA for photos and images taken described above.
It is, however, not a requirement of KCCP. The participants do not agree to grant the
participants themselves portrait right license to JICA, has absolutely no problem in
participating KCCP. JICA respects the intention of each Participant.

DECLARATION (to be signed by Applicant)

・I understand and fully agree to the following terms and conditions set forth above.
1. General Rule
2. Privacy Policy
3. Copyright Policy

・I will be subject to any penalties imposed as a consequences of my failure to abide by the

above terms and conditions.

・I understand the intention of JICA on “4.Portrait Right Policy” mentioned above, and my
intention for usage/publication of photographs and videos including the portrait of myself
by JICA for the purposes above is as follows:
□ Agree ／ □ Disagree
・I certify that the statements I made in this form are true, complete and correct to the best of
my knowledge and belief.

By Applicant
Date
Name
Signature

14