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VISA APPLICATION FORM TO ENTER JAPAN
(Paste photo here)
45mm ×45mm
*Official use only
or 2in×2in
Surname (as shown in passport) BUI
Given and middle names (as shown in passport) DUC LUONG
Other names (including any other names you are or have been known by)
Date of birth 29/07/2003 Place of birth HA GIANG
(Day)/(Month)/(Year) (City) (State or Province) (Country)
Sex: Male Female Marital status: Single Married Widowed Divorced
Nationality or citizenship VIET NAM
Former and/or other nationalities or citizenships
ID No. issued to you by your government 002203003351
Passport type: Diplomatic Official Ordinary Other
Passport No. E01449050
Place of issue HA NOI, VIET NAM Date of issue 22/03/2024
(Day)/(Month)/(Year)
Issuing authority IMMIGRATION DEPARTMENT Date of expiry 22/03/2024
(Day)/(Month)/(Year)
Purpose of visit to Japan SHORT-TERM STUDY PROGRAM
Intended length of stay in Japan 84 DAYS
Date of arrival in Japan 08/05/2024
Port of entry into Japan NARITA Name of ship or airline VJ932
Names and addresses of hotels or persons with whom applicant intends to stay
Name DORMITORY OF FPT JAPAN ACADEMY Tel. 03-5615 - 1012
Address 114 - 005 TOKYO, KITA KU, SAKAECHO 19-12, ROMAN TEI 1
Dates and duration of previous stays in Japan NO
Your current residential address (if you have more than one address, please list them all)
THACH HOA, THACH THAT, HA NOI, VIETNAM
Address
Tel. Mobile No. +84 354022820
Current profession or occupation and position STUDENT
Name and address of employer
Name FPT UNIVERSITY HANOI CAMPUS Tel. +84 24 7300 18
EDUCATION ZONE, HOA LAC HI-TECH PARK, KM29, THANG LONG BOULEVARD, THACH
Address HOA, THACH THAT, HANOI, VIETNAM
*Partner's profession/occupation (or that of parents, if applicant is a minor):
Guarantor or reference in Japan(Please provide details of the guarantor or the person to be visited in Japan)
Name HIDEO KURODA Tel. 03-5615 - 1012
Address 116-0014 TOKYO, ARAKAWA, HIGASHI NIPPORI 4-3-5
Date of birth 27/3/1944 Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant PRINCIPAL OF HOSTING INSTITUITION
Profession or occupation and position PRINCIPAL OF FPT JAPAN ACADEMY
Nationality and immigration status JAPANESE
Inviter in Japan(Please write 'same as above' if the inviting person and the guarantor are the same)
Name SAME AS ABOVE Tel. SAME AS ABOVE
Address SAME AS ABOVE
Date of birth Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant SAME AS ABOVE
Profession or occupation and position SAME AS ABOVE
Nationality and immigration status SAME AS ABOVE
*Remarks/Special circumstances, if any
Have you ever:
● been convicted of a crime or offence in any country? Yes No
● been sentenced to imprisonment for 1 year or more in any country?** Yes No
● been deported or removed from Japan or any country for overstaying your visa or violating
any law or regulation? Yes No
● been convicted and sentenced for a drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances?** Yes No
● engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
persons, or in the provision of a place for prostitution, or any other activity directly
connected to prostitution? Yes No
● committed trafficking in persons or incited or aided another to commit such an offence? Yes No
** Please tick “Yes” if you have received any sentence, even if the sentence was suspended.
If you answered “Yes” to any of the above questions, please provide relevant details.
“I hereby declare that the statement given above is true and correct. I understand that immigration status and period of stay to
be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not
entitle the bearer to enter Japan upon arrival at port of entry if he or she is found inadmissible.”
“I hereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing
my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the
Japanese embassy/consulate-general, when such payment is necessary.”
Date of application Signature of applicant
(Day)/(Month)/(Year)
* It is not mandatory to complete these items.
Any personal information gathered in this application as well as additional information submitted for the visa application
(hereinafter referred to as "Retained Personal Information”) will be handled appropriately in accordance with the Act on the
Protection of Personal Information Held by Administrative Organs (Act No. 58 of 2003, hereinafter, “the Act”). Retained Personal
Information will only be used for the purpose of processing the visa application and to the extent necessary for the purposes
stated in Article 8 of the Act.
