NATIONAL YOUTH COMMISSION

Kizuna (Bond) Project

APPLICATION FORM FOR STUDENTS

AREA TO BE REPRESENTED: LUZON VISAYAS MINDANAO NCR

1. Surname:
Fortunato___________________ Passpor
______ 2. Gender: [ M ] [ F ] t-sized
photo
First Name: Julienne
_________________________ 3.
Height: 5 5 ft
Middle Name:
_Ledang_______4. Weight: 56
kg 5. Age: 20 yrs old

Nickname: Julyen 6. Birth

date: July 28, 1992 7.
_______
Birthplace: Benguet _______
_______
8. Residence/Mailing Address: __
#628 Camp Henry T. Allen, Pls.
Indicate
Baguio City 2600 date
taken
9. Years of Stay: 14 10. Tel.
No. (landline/Area Code):
423-1384

1. Zip Code:2600 12.

Email Address:
julienne.july.fortunato
@gmail.com
13. Mobile No.: 09269187800/
09203432415 14. Religion:
Anglican
15. Passport Number:

*Applicants email address and mobile

number are mandatory.

16. Fathers Name: Tomas B. Pl Occupat

Fortunato ac ion: Bus
e Inspecto
of r
Bi
rt
h:
Su
yo
c,
M
an
ga
ka
ya
n,
Be
ng
ue
t
17. Mothers Name: Olivia L. Pl Occupat
Fortunato ac ion:
e Govern
of ment
Bi Employ
rt ee
h:
Sa
n
G
ab
rie
l,
La
U
ni
on
18. No. of Brother/s 1
19. No. of Sister/s 4
20. Educational Background Na Year / Honors Received
m Course
e
of
Sc
ho
ol/
Un
ive
rsi
ty/
Ad
dr
es
s
Be BS Deans List (1st sem SY
ng Developme 2009-2010)
ue nt
t Communica
St tion
College / University at
e
Un
ive
rsi
ty
Un BA in Mass Deans List (SY 2010-2013)
ive Communica
rsi tion and BA
ty in English
of
th
e
Co
rdi
lle
ras

21. Scholarship Grants Do Inclusive Honors Received

no Dates
r
Un SY
ive 2012-2013
rsi
ty
St
ud
en
t
Co
un
cil
Pr
esi
de
nt
Sc
ho
lar
shi
p
Gr
an
 t

22. Youth Organization/Youth

Serving Organization Affiliations:
Name of Organization Position Years of Acco
Members mplis
hip hme
nts
University Student Council Presiden SY 2012- Stude
t present nts
aware
ness
in
Cordill
era
Cultur
e,
Curre
nt
Situati
on
and
Organ
ic Act,
Stude
nts
Involv
emen
t
Mass Communication Society Secretar SY Laun
y 2011-201 ching
2 of
Sine
ma
Berd
e
Mass Communication Society Member SY
2010-201
1
Hapiyoh Mi Cultural Dance Troupe Public SY 2011-
Relation present
s Officer
23. Special Skills or Talents:

24. Food Restrictions: 25.

Allergies

Food
Coloring
Tartrazin
e Yellow
5
26. Dialect(s) or Foreign Language(s)
Spoken:

Ilocano, Kankana-ey, Filipino, English

27. Title of Seminar/Training Course Inclusive Dates No. of C
Attended Hours o
n
d
u
ct
e
d
b
y
7th Aboitiz Future Leaders Business August 30 A
Summit (Nationwide) 16-18,2012 b
oi
ti
z
gr
o
u
p
of
c
o
m
p
a
n
y
1st Ayala Leadership Communities May 21-23, 2012 40 A
Baguio- Benguet (Provincial wide) y
al
a
F
o
u
n
d
at
io
n,
In
c.
CHED Orientation on the enhanced May 30, 2012 8 C
policies (Nationwide) o
m
m
is
si
o
n
o
n
Hi
g
h
er
E
d
u
ca
ti
o
n
Hapiyoh Mi Summer Cultural April 26-30, 60 H
Workshop 2012 2012 a
(Region wide) pi
y
o
h
M
i
D
a
n
c
e
tr
o
u
p
e
p
ar
tn
er
sh
ip
w
it
h
N
at
io
n
al
Y
o
ut
h
C
o
m
m
is
si
o
n
a
n
d
N
at
io
n
 al
C
e
nt
er
fo
r
C
ul
tu
re
a
n
d
th
e
A
rt
s
Seminar-Workshop Writing Beyond April 11-13, 30 P
Printed Words (Luzon wide) 2012 hi
li
p
pi
n
e
Pr
es
s
In
st
it
ut
e
w
it
h
T
h
e
C
o
ca
C
ol
a
E
x
p
or
t
C
or
p
or
at
io
n
28. Character References:
[not related to you within the third
degree of consanguinity]

Name O Add
cc ress
up and
ati Tele
on pho
ne
No.
Dr. Cleofas M. Basaen V
P
fo
r
Ac
ad
e
mi
c
Af
fai
rs,
U
ni
ve
rsi
 ty
of
th
e
Co
rd
ill
er
as
Dr. Miriam A. Janeo D
ea
n,
Co
lle
ge
of
Ar
ts
an
d
Sc
ie
nc
es
,
U
C
Engr. Aloysius C. Mapalo D
ea
n,
Of
fic
e
of
St
ud
en
t
Af
fai
rs
an
d
Se
rvi
ce
s
Atty. Roney Jone P. Gandeza U
ni
ve
rsi
ty
St
ud
en
t
Co
un
cil
,
A
dv
is
er
29. How did you know about the 30.
program? Have
you
Newspaper: _____ been
Radio: ______ a
partici
Magazine: _____ pant
TV Ads: ______ of any
NYC
Others [pls. Indicate]: Office of Intern
Students Affairs and Services ationa
l
Excha
nge

Progra
m? [
] No
[ ]
Yes
 If
yes,
please
indicat
e the
Progra
m,
year
and
source
of
fund
Please fill up form legibly

31. Have you rendered voluntary service for the NYC? ? [ ] No [ ] Yes
If yes, please state nature of service and how long

32. Have you availed of any program or scholarship grant offered by the
Japanese government? [ ] No [ ] Yes
If yes, please indicate the program and year

33. Are you on a scholarship granted by the Department of Science and

Technology (DOST)? [ ] No [ ] Yes

34. Have you attended any seminar, conference or trainings abroad? [ ]

No [ ] Yes
If yes, please indicate the program and year

35. Have you been involved with any NYC local program or activity? [ ]
No [ ] Yes
If yes, please indicate the program(s) and year
36. Have you ever been convicted of any crime involving moral turpitude?
[ ] No [ ] Yes
If yes, please indicate the nature and status

37. Do you have any pending case? [ ] No [ ] Yes

If yes, please indicate the nature and status

CONFORME

I hereby certify upon my honor that all facts and information indicated herein
are true and correct to the best of my knowledge. I further declare that any
information given by me that is untrue may constitute a ground for expulsion in the
Kizuna (Bond) Project and prosecution for perjury.

Further, I subscribe and agree that the National Youth Commission has the
sole prerogative to select and nominate the delegates to the Kizuna (Bond) Project,
and its decision is final and executory.

IN WITNESS hereof, I am executing and signing this statement voluntarily

without compulsion.
 PARENTAL CONSENT

I am the parent/legal guardian of

__________________________________________ and he/she has applied in the
Kizuna (Bond) Project with my consent. In the event that the National Youth
Commission chooses him/her, I am hereby giving him/her permission to travel
under the supervision of the chosen Supervisors of the Kizuna (Bond) Project.

Attested by:

________________________________

*Signed by a witness not a relative by consanguinity/affinity up to the 4th degree

civil degree.
QUALIFICATIONS AND OBLIGATIONS OF STUDENTS APPLICATION REQUIREMENTS FOR STUDENTS

Filipino, single, 18 years old to 24 years old as of August 1, 2012; must be
college/university-level students. Freshmen to Senior college/university students are
qualified to apply;
Of good moral character;
Must be currently enrolled in a college or university with a Graded Weight Average (GWA)
of 2.25 or 85% equivalent, with no failing marks in the preceding semester
Physically and mentally fit to travel;
Preferably must be a first time traveler to Japan and must not have been a grantee or
recipient of any NYC- coordinated international invitation to Japan. Those who have
visited Japan on various schemes (i.e. privately-funded vacation, other Japanese
Government youth exchange schemes, etc.) will be allowed to participate provided that
their most recent stay in Japan did not exceed three (3) months. Former JENESYS
Programme Student Ambassadors are NOT qualified to join;
Must be knowledgeable of the history, geography, culture and arts, and the current issues
on the Philippines, and fairly knowledgeable in those of Japan and other countries in East
Asia;
Preference will be given to applicants who are currently studying/have studied Japanese
language and culture subject or courses;
Must be an officer or an active member of a youth organization for at least one (1) year
immediately preceding the date of application;
Area representation shall be based on the place of the college or university enrolled in;
One (1) copy of the Entry Form for Kizuna (Bond) Project with picture
One (1) copy of Letter of Consent with Medical Certificate issued by a medical institution
if the applicant has any chronic disease
Two (2) photocopies of passport, if there is a passport already (page of face photo and
personal information. If expired but extended, with a page that states extension as well
Two (2) copies of short essay which states the student ambassadors: a)Main reasons for
applying; b)Expectations from the exchange project; c) What can he/she contribute to
recovery after disasters like the recent Great East Japan Earthquake?; d) After returning
to the Philippines, how can he/she put to use the lessons learned from this project?
(Maximum of 100 words per question)
One (1) copy of the NYC application form with passport sized picture with white
background attached to the application form (no scanned picture)
One (1) photocopy of Birth Certificate (from the National Statistics Office-NSO)
One (1) copy of resume, not more than three (3) pages
One (1) copy of Certificate of Good Moral Character, issued by the college or university
and stating that the applicant has a Graded Weight Average (GWA) of 2.25% or 85%
equivalent, with no failing marks in the preceding semester
One (1) copy of completed NYC Volunteer Form
One (1) original copy of Certification from school or organization that the applicant is an
officer or active member

Must be willing to be an active NYC and JICC volunteer after the program to continue to
Participants of any NYC-coordinated international program from 2010-2012
promote the learnings about Japan and the Japanese culture gained from the Kizuna
(Bond) Project;
which round-trip airfare, food and accommodation were borne by the
organizer/s are disqualified from participating.
The students are required to write a post-program report/essay (minimum of 300 words);
and
All students are encouraged to take a more active role in promoting the various Japanese
Participants of any NYC-coordinated international program from 2011-2012
Government youth exchange programs and Japanese Government Scholarship programs which round-trip airfare was shouldered by the participants are also
and share their experiences through social media (facebook, twitter) after the project. disqualified to participate.

Please take note that the NYC, JICE and JICC shall not allow a delegate to participate to the * Passport must be valid six (6) months after the date of departure
project if: * Submit only the required documents
 a. she is pregnant to ensure safety and well-being
b. he/she has any chronic disease and previous diseases without a letter of consent
from himself/herself and his/her parents and a doctors certificate to avoid expensive
medical fees for chronic-related diseases which is not covered by overseas travel
insurance but will be borne by him/herself.
NOTE:
Deadline for submission of application form is September 28, 2012.
The National Youth Commission reserves the right and prerogative to exclude
applicants who will not meet the minimum requirements of the Program. Lack
or non-compliance of any of the above stated requirements will mean
automatic disqualification without notice.
Mail or hand carry your application to Ms. Marielou A. Chua, National Youth
Commission, 4th Flr., Bookman Building, 373 Quezon Avenue, Quezon City, Tel
No. 416-2833
Please fill up the form legibly