Date Received 2011 Month Day

Test Level
Test Site		 KATHMANDU

Name

Note : Please use 26 English letters only. Your name will be printed on the score reports as you write.

Sex
Male
Female
Date of Birth

Year
Month
Day

Nationality / Citizenship
Native language

Street - Suburb

City - State

Country - Area

Postal Code

Telephone No.

Fax No.

E-mail

Address

Institute where you are studying ( or studied )
Japanese-Language

Place of learning Japanese (Choose a number from 1 to 6)

Reason for taking this exam (Choose a number from 1 to 8)

Level(s) previously passed (Select from Table)

2008 through 2010 test results ( Select from Table2 )

Occupation ( Choose a number from 1 to 6 )

Occupational details ( Choose a number from 1 to 6 )

Media via which you come into contact with Japanese language

1

2

3

4

5

6

7

8

9
 
Speaking
Listening
Reading
Writing
None of the above

The person with whom you usually communicate in Japanese
with a Teacher

1

2

3

4

5
with Friends

1

2

3

4

5
with Family

1

2

3

4

5
with a Supervisor

1

2

3

4

5
with Colleagues

1

2

3

4

5
with Customers

1

2

3

4

5
MAILING
ADDRESS
 
 
( For sending the test results and certificates )

Name

Address
 
Telephone No. Country . Area