World Campus International, Inc.

Support World Campus
International, Inc.!

World Campus International, Inc.
Dai 2 Ebisu Heights #101
4-17-8 Ebisu
Shibuya-ku, Tokyo 150-0013
Japan

To Contact Us in Japanese:
Phone: Japan: +81 3 3473 1120
Fax: +81 3 5475 5842
Email: hyasui@worldcampus.org

To Contact Us in English:
Phone: USA: +1 303 495-2078
Toll free in the USA and Canada:
+1 866 595-6323
Fax: +1 303 495-2069
Email: yhufford@worldcampus.org

World Campus - Japan

Please Complete and Send the Following Information to Submit your Application.
You can also fill out, print our pdf-Application form and fax to Yoshimi Hufford
at +1 303 495-2069.

ATTENTION: This is the Application Form of the World Campus - Japan program. If you are looking for the World Campus Teachers Initiative Application, please fill out the WCTI-application form.

Upon completion of your application, please email Yoshimi Hufford at yhufford@worldcampus.org to confirm that your submitted application has been received. Thank you!

1. Personal Information

*First Name
Middle (if applicable)
*Last Name
Nickname or Name that you Prefer to be Called
*Birth Date (mm/dd/yyyy)
*Email Address
Skype Address
*Full Address as Written for International Mail
*Address Valid until When?
Permanent Residential Address (if different from above)
*Home Phone with Country and City Codes
Mobile Phone with Country and City Codes
*Country / Countries to which you Hold a Passport
*Birth Country
*Country you Wish to Represent on Tour
GenderMale Female
*What Ethnicity do you Consider yourself?

2. Education, Profession & Language:

Please Describe your Most Recent Completed Level of Education
Are you Currently Enrolled at a College or University? (if no, please skip to the highlighted section below) Yes No
Please Describe the Nature of your Studies and Intended Degree upon Graduation
What is the Name and Full Address of your College or University?
Please Provide a Phone Number and / or Web or Email Address for your School
Do you Plan to Seek Academic Credit with your School for your Participation in our Program?
If you are not in College/University, Please Describe your Current School, Job or Profession
What is the Name and Full Address of your Current School or Employer?
Please Provide a Phone Number and / or Web or Email Address for your School or Employer
*Native Language
Additional Language
Written Fluency: High Moderate Low
Spoken Fluency: High Moderate Low
Additional Language
Written Fluency: High Moderate Low
Spoken Fluency: High Moderate Low
Additional Language
Written Fluency: High Moderate Low
Spoken Fluency: High Moderate Low
Additional Language
Written Fluency: High Moderate Low
Spoken Fluency: High Moderate Low

3. Sessions

Which Session are you Applying for?
Summer 2010 Sessions
more than one Session:
Session 1: June 5^th - June 19^th 2010
Session 2: June 23^rd - July 7^th 2010
Session 3: July 11^th - July 25^th 2010
Session 4: July 29^th - August 12^th 2010
Session 5: August 16^th - August 30^th 2010
Have you Applied to Travel with World Campus International, Inc. Before? Yes No
If Yes, Please State Which Session you had Applied for
Please Describe how you First Heard about World Campus International, Inc.?

4. Recommendation Contact Information

Please list the name of an English speaking, non-relative who will act as your recommendation. World Campus International reserves the right to decide whether or not to contact this person.

*Full Name
*GenderMale Female
*E-mail Address
*Telephone Number with Country and City Codes
*Available Times to be Reached
*What is your Relationship to this Person?
*How Long have you Known this Person?

5. Volunteerism, Community Involvement Activities or Awards received:

Please provide a short description and dates of involvement or when you received awards.

6. Please describe in the space provided below the following:

What do you believe you will gain from attending this program?
What can you contribute to make the experience the best it can be for both your fellow participants and the communities on tour?

-Please fill in control number ->

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