NATIONAL BOARD FOR THE PLACEMENT AND PROTECTION

INDONESIAN OVERSEAS WORKERS

J l. MT. Haryono Kav. 52 J akarta Selatan-17220, Lt. 5,
Telp./Fax. : 021-7901158
Form 6

Information Sheet of Applicants for Indonesian
Candidate for Kaigofukushishi

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

Date of birth _____________________________________ Age ___________


Address_______________________________________________________


Telephone number______________________________________________

Spouse/Dependent children
Number 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 __________________________________________________________

J apanese Langguage Proficiency
Level of J apanese Language Proficiency Test conducted by the J apan Foundation or J apan
Educational Exchanges and Services ( if any ) : ______
Number of years of studying J apanese (if any, most recent first)
From
(year)
To (year) J apanese Language Institution Country










Photo
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 fixed
days 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

Region
Hokkaido ______ 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 J apanese language ability, for example, certificates of the
J apanese-Language Proficiency Test (Level 1 or 2) should be attached if you wish to
be exempted from J apanese language training in J apan.
NATIONAL BOARD FOR THE PLACEMENT AND PROTECTION
INDONESIAN OVERSEAS WORKERS
J l. MT. Haryono Kav. 52 J akarta Selatan-17220, Lt. 5,
Telp./Fax. : 021-7901158
Form 5

Information Sheet of Applicants for Indonesian
Candidate for Kangoshi

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

Date of birth _____________________________________ Age ___________


Address _______________________________________________________


Telephone number______________________________________________

Spouse/Dependent children
Number 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)
Degree
Obtained




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)

Photo
J apanese Langguage Proficiency
Level of J apanese Language Proficiency Test conducted by the J apan Foundation or J apan
Educational Exchanges and Services ( if any ) : ________
Number of years of studying J apanese (if any, most recent first)
From (year) To (year) J apanese 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 fixed
days 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

Region
Hokkaido ______ 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 attached
Note 6 Fill this form for all applicants and gather.
Note 7 Documents to certify J apanese language ability, for example, certificates of the
J apanese-Language Proficiency Test (Level 1 or 2) should be attached if you wish to
be exempted from J apanese language training in J apan.