CONFIDENTIAL

Guidelines of Application Form for

the JICA Knowledge Co-Creation Program

The attached form is to be used to apply for the Knowledge Co-Creation program (KCCP)
of the Japan International Cooperation Agency (JICA), which are implemented as part of
the Official Development Assistance Program of the Government of Japan. Please
complete the application form while referring to the following and consult with the
respective country’s JICA Office - or the Embassy of Japan if the former is not available - in
your country for further information.

1. Parts of Application Form to be completed

1) Which part of the form should be submitted?
It depends on the type of KCCP you are applying for.
>Application for KCCP (Group and Region Focus)
Official application and Parts A and B including Medical History must be submitted.

>>Application for KCCP (Country Focus) including KCCP for Counterpart and KCCP
related to ODA Loan
Official Application and Part B including Medical History will be submitted. Part A needs not
to be submitted.

2) How many parts does the Application Form consist of?

The Application Form consists of three parts as follows;
Official Application
This part is to be confirmed and signed by the head of the relevant department/division of
the organization which is applying.

Part A. Information on the Applying Organization

This part is to be confirmed by the head of the relevant department/division of the
organization which is applying.

Part B. Information About the Nominee including Medical History

This part is to be completed by the person who is nominated by the organization applying.
The applicants for KCCP (Group and Region Focus) are required to fill in every item. As
for the applications for KCCP (Country Focus) including KCCP for Counterpart and some
specified programs, it is required to fill in the designated “required” items as is shown on
the Form.

Please refer to the General Information to find out which type KCCP that your organization
applies for belongs to.

2. How to complete the Application Form

In completing the application form, please be advised to:
(a) carefully read the General Information (GI) for which you intend to apply, and confirm if
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the objectives and contents are relevant to yours,

(b) be sure to write in the title name of KCCP accurately according to the GI, which you
intend to apply,
(c) use a typewriter/personal computer in completing the form or write in block letters,
(d) fill in the form in English,
(e) use or “x” to fill in the ( ) check boxes,
(f) attach a picture of the Nominee,
(g) attach additional page(s) if there is insufficient space on the form,
(h) prepare the necessary document(s) described in the General Information (GI), and
attach it (them) to the form,
(i) confirm the application procedure stipulated by your government, and
(j) submit the original application form with the necessary document(s) to the responsible
organization of your government according to the application procedure.

Any information that is acquired through the activities of the Japan International
Cooperation Agency (JICA), such as the nominee’s name, educational record, and medical
history, shall be properly handled in view of the importance of safeguarding personal
information.

3. Privacy Policy
1) Scope of Use
Any information used for identifying individuals that is acquired by JICA will be stored, used,
or analyzed only within the scope of JICA activities. JICA reserves the right to use such
identifying information and other materials in accordance with the provisions of this privacy
policy.

2) Limitations on Use and Provision

JICA shall never intentionally provide information that can be used to identify individuals to
any third party, with the following three exceptions:
(a) In cases of legally mandated disclosure requests;
(b) In cases in which the provider of information grants permission for its disclosure to a
third party;
(c) In cases in which JICA commissions a party to process the information collected; the
information provided will be within the scope of the commissioned tasks.

3) Security Notice
JICA takes measures required to prevent leakage, loss, or destruction of acquired
information, and to otherwise properly manage such information.

4. Copyright policy
Participants of KCCP are requested to comply with the following copyright policy;

Article 1. Compliance matters with participants’ drafting of documents (various reports,

action plans, etc.) and presentations (report meetings, lectures, speeches, etc.)
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1. Any contents of the documents and presentations shall be created by themselves in

principle.
2. Comply with the following matters, if you, over the limit of quotation, have to use a third
person’s work (reproduction, photograph, illustration, map, figure, etc.) that is protected
under laws or regulations in your country or copyright-related multinational agreements or
the like:
(1) Obtain license to use the work on your own responsibility. In this case, the scope of the
license shall meet the provisions of Article 2.
(2) Secure evidential material that proves the grants of the license and specifies the scope
of the license.
(3) Consult with the third party and perform the payment procedure on your own
responsibility regarding negotiations with a third person about the consideration for granting
the license and the procedure for paying the consideration.

Article 2. Details of use of works used for KCCP

(1) The copyright on a work that a participant prepares for KCCP shall belong to the
participant. The copyright on the parts where a third party’s work is used shall belong to the
third party.
(2) When using texts, supplementary educational materials and other materials distributed
for KCCP, participants shall comply with the purposes and scopes approved by each
copyright holder.
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Knowledge Co-Creation Program under Technical Cooperation with the Government of Japan

Application Form for the JICA Knowledge Co-Creation Program

OFFICIAL APPLICATION
(to be confirmed and signed by the head of the relevant department / division of the applying organization)

1. Title: (Please write down as shown in the General Information)

GENERAL MANAGEMENT FOR REGIONAL DEVELOPMENT AND PLANNING

2. Number: (Please write down as shown in the General Information)

J 1 7 - 0 4 0 9 3

3. Country Name:
Tajikistan

4. Name of Applying Organization:

State Executive Body for Sugd region

5. Name of the Nominee(s):

1) Nigora Ghafforzoda 3)
2) 4)

Our organization hereby applies for Knowledge Co-Creation program of the Japan International
Cooperation Agency and proposes to dispatch qualified nominees to participate in the programs.

Date: 22.06.2017 Signature:

Name: Abdullozoda Sharifullo

Designation / Position Head of Department

Regional Department for Economic Development
Department / Division and Trade Official Stamp
Address: Rahmon Nabiev ave. 45, Building of State Executive
Office Address and Body for Sugd region, 5th floor
Contact Information Telephone: +99283422 4- Fax: +99283422 4-6588 E-mail: [email protected]
6573

Confirmation by the organization in charge (if necessary)

I have examined the documents in this form and found them true. Accordingly I agree to
nominate this person(s) on behalf of our government.

Date: 22.06.2017 Signature:

Name: Abdullozoda Sharifullo Official Stamp

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Designation / Position Head of Department

Regional Department for Economic Development
Department / Division and Trade
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Part A: Information on the Applying Organization

(to be confirmed by the head of the department / division)

1. Profile of Organization

1) Name of Organization:
State Executive Body for Sugd region

2) The mission of the Organization and the Department / Division:

Foreign Economic Affairs Department is a subdivision of the Regional Department for
Economic Development and Trade and its main functions are:
- Designation and implementation of a unified state trade policy, cooperation with the
World Trade Organization;
- State monitoring of the foreign economic activities;
- Analyze of the development of foreign economic activities for the purpose of
determination of the preferred directions of cooperation and finding partners and
investors in the field of foreign economic relations;
- Designation of concepts, short-term, mid-term and long term strategies,
development programs for foreign trade and consumption markets;
- Participation in coordination processes of opening cross border trading centers and
near the border markets
- Participation in the process of state support for private sector and entrepreneurship,
development of trading, scientific and technical relations together with foreign
partners, which promotes entrepreneurship development.

2. Purpose of Application

1) Current Issues: Describe the reasons for your organization claiming the need to
participate in Knowledge Co-Creation Program (KCCP), with reference to issues or
problems to be addressed.
There are 18 towns and districts and 125 jamoats (small communities) of these towns and
districts are located in Sugd region. The level of social and economic development of these
jamoats are different. Those jamoats, which are closer located with the center of Sugd
region or other towns/districts centers have a better development. Remote jamoats of Sugd
are well behind in terms of social and economic development. The level of peoples’ living is
not equal either. Water supply, infrastructure and social well-being in many jamoats are in a
great need of changes.

2) Objective: Describe what your organization intends to achieve by participating in

KCCP.
The expectation of our organization is that by participating in this program I can learn the
experience of other countries in terms of sustainable development provision for all regions.
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3) Future Plan of Actions: Describe how your organization shall make use of the expected
achievements, in addressing the said issues or problems.
After learning the experience of developed countries, our organization will use my gained
knowledge and experience during designation of sectorial and regional programs and
provision of equal development in all regions of Sugd. Also I will take an active part in
implementation of the strategy of Sugd economic safety and food security.

4) Selection of the Nominee: Describe the reason(s) the nominee has been selected for
the said purpose, referring to the following view points; 1) Course requirement, 2)
Capacity /Position, 3) Plans for the candidate after the KCCP , 4) Plan of organization and 5)
Others.
The main reasons that our employer has been selected for the program is that 1) we need
a better quality of designation of state programs and the strategy of export development
and foreign trading 2) clearly prepare conclusions and suggestions to the drafts of
interregional and international documents of Sugd region in the field of taxation and
avoidance from paying taxes.
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Part B: Information about the Nominee

(to be completed by the Nominee)
NOTE>>>The applicants for Knowledge Co-Creation Program (KCCP) are required to fill in “Every Item”. As for the
applications for KCCP (Country Focus) including KCCP for Counterpart and some specified programs, it is required to
fill in the designated “required” items as is shown below.

1. Title: (Please write down as shown in the General Information) (required) Attach the
GENERAL MNAGEMENT FOR REGIONAL DEVELOPMENT AND PLANNING nominee’s
photograph (taken
2. Number: (Please write down as shown in the General Information) (required)
within the last three
months) here
J 1 7 - 0 4 0 9 3
Size: 3x4
(Attach to the
3. Information about the Nominee (nos. 1-9 are all required) documents to be
submitted.)
1) Name of Nominee (as in the passport)
Family Name
G H A F F O R Z O D A
First Name
N I G O R A
Middle Name

2) Nationality 5) Date of Birth (please write out the

(as shown in the passport) month in English as in “April”)
3) Sex ( ) Male (●) Female Date Month Year Age
4) Religion Islam 19 April 1979 38

6) Passport/Visa
Passport possession (●) Yes ( )No Expiry date Date Month Year
USA visa possession ( ) Yes (●)No of passport

<ATTENTION>
(1)If you apply from ①Mexico, ②Guatemala, ③Haiti,　④Rep. of Dominica, ⑤St. Christopher and
Nevis,　⑥Antigua and Barbuda, ⑦Dominica, ⑧St. Lucia, ⑨Barbados, ⑩St. Vincent and the
Grenadines,
⑪Grenada, ⑫Guyana, ⑬Suriname, ⑭Venezuela, ⑮Colombia, ⑯Ecuador, ⑰Peru, ⑱Bolivia,
⑲Chile, ⑳Argentina(only for Japanese descendant), or (21)Brazil, and you have a passport with a
valid U.S. visa, please attach herewith a copy of Identification Pages on the inside cover of your
passport (these are the two pages that include your photograph and your detailed passport
information) and the page of U.S. visa.

(2)If you apply from ①Belize, ②El Salvador, ③Honduras, ④Nicaragua, ⑤Costa Rica, ⑥Panama,
⑦Jamaica, ⑧Trinidad and Tobago, ⑨Paraguay, ⑩Uruguay, ⑪Palau, ⑫Marshall, or ⑬Micronesia,
and you have a passport, please attach herewith a copy of Identification Pages on the inside cover
of your passport (these are the two pages that include your photograph and your detailed passport
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information).

7) Present Position and Current Duties

Organization Regional Department for Economic Development and Trade

Department / Division Foreign Economic Affairs Department

Present Position Head of Department

Date of employment by Date Month Year Date of assignment to the Date Month Year
the present organization 16 March 2014 present position 7 March 2016

8) Type of Organization
( ) National Governmental (●) Local Governmental ( ) Public Enterprise
( ) Private (profit) ( ) NGO/Private (Non-profit) ( ) University
( ) Other ( )

9) Outline of duties: Describe your current duties

1) Implementation of state activity in the field of foreign economic relations;
2) Analyze of the development of foreign economic activities for the purpose of
determination of the preferred directions of cooperation and finding partners and investors
in the field of foreign economic relations;
3) Designation of concepts, short-term, mid-term and long term strategies, development
programs for foreign trade and consumption markets;
4) Clearly prepare conclusions and suggestions to the drafts of interregional and
international documents of Sugd region in the field of taxation and avoidance from paying
taxes;
5) State support for private sector and entrepreneurship activities, development of trading,
scientific and technical relations together with foreign partners, which promotes
entrepreneurship development.

10) Contact Information

Address: Khujand city, Rahmon Nabiev ave. 45
Office TEL: +99283422 4-6576 Mobile (Cell Phone): +99292 777-0384
FAX: E-mail: [email protected]

Address: Sugd region, Konibodom town, Pulodon jamoat, Rudaki street #8

Home TEL: +99283467 3-4975 Mobile (Cell Phone): +99292 777-0384
FAX: E-mail: [email protected]
Name: Unusov Farrukh
Relationship to you: Husband
Contact person
Address: Sugd region, Konibodom town, Pulodon jamoat, Rudaki street #8
in emergency
TEL: +99283422 4-6576 Mobile (Cell Phone): +99292 760 4975
FAX: E-mail: [email protected]

11) Others (if necessary)

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4. Career Record
1) Job Record (After graduation)
Period
City/
Organization From To Position or Title Brief Job Description
Country
Month/Year Month/Year

October/20 October/20 In charge of employment

OJSC “Kanibadam” Tajikistan Economist
01 04 salaries department

October/20 In charge of goods export

LLC “Alikhuja” Tajikistan May/2006 Deputy Director
04 and foreign affairs

Promotion of income level of

Red crescent society
Sugd population project
of Tajikistan, regional Tajikistan June/2006 April/2009 Administrator
European Commission
representative
program
In charge of reducing
January/20 electricity suffering and
LLC “Gaffor Aliev” Tajikistan April/2009 Director
12 energy saving and energy
efficiency
Inspector of state monitoring State monitoring on
January/20 March/201
State Agency “TajikStandart” Tajikistan on electricity counting electricity counting
12 5
machines equipment
Senior specialist at the Facilitating women’s’ family
State Executive Body For Sugd March/201 January/20
Tajikistan Department for women and relations, improving the
region 5 16
families affairs living condition of women
Coordination of state
Head of the Foreign activities on foreign
State Executive Body For Sugd January/20 Present
Tajikistan Economic Affairs relations, facilitating the
region 16 time
Department development of foreign
policy of Tajikistan

2) Educational Record (Higher Education) (required)

Period
City/
Institution From To Degree obtained Major
Country
Month/Year Month/Year

Tajik State University of Law, September

Tajikistan July/2001 University diploma International economy
Business and Politics /1996

Academy of Science of the Present

Tajikistan June/2014 Expecting Political science
Republic of Tajikistan time

3) Training or Study in Foreign Countries; please write your past visits to Japan specifically as
much as possible, if any.
City/ Period
Institution Field of Study / Program Title
Country From To
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Month/Year Month/Year
October/20 November/
US State Department USA IVLP
13 2013

5. Language Proficiency (required)

1) Language to be used in the program (as in GI)

Listening ( ) Excellent (●) Good ( ) Fair ( ) Poor

Speaking ( ) Excellent (●) Good ( ) Fair ( ) Poor

Reading (●) Excellent ( ) Good ( ) Fair ( ) Poor

Writing ( ) Excellent (●) Good ( ) Fair ( ) Poor

Certificate (Examples: TOEFL, TOEIC)

2) Mother Tongue Tajik

3)Other languages ( Russian ) (●) Excellent ( ) Good ( ) Fair ( ) Poor

Excellent: Refined fluency skills and topic-controlled discussions, debates & presentations. Formulates strategies to
deal with various essay types, including narrative, comparison, cause-effect & argumentative essays.
Good: Conversational accuracy & fluency in a wide range of situations: discussions, short presentations & interviews.
Compound complex sentences. Extended essay formation.
Fair: Broader range of language related to expressing opinions, giving advice, making suggestions. Limited compound
and complex sentences & expanded paragraph formation.
Poor: Simple conversation level, such as self-introduction, brief question & answer using the present and past tenses.
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6. Expectation on the applied KCCP

1) Personal Goal: Describe what you intend to achieve in the applied KCCP in relation to the
organizational purpose described in Part A-2.
Promotion of knowledge in the area of local government’s activities and utilization of
knowledge and skills during designation of regional development programs.

2) Relevant Experience: Describe your previous vocational experiences which are highly relevant
in the themes of the applied KCCP. (required)
Institution for State Management under the President of the Republic of Tajikistan, course
title: New State Management.

3) Area of Interest: Describe your subject of particular interest with reference to the contents of the
applied KCCP. (required)
I am interested to get a better knowledge about the state management and public-private
management of Japan.

*7. Declaration (to be signed by the Nominee) (required)

I certify that the statements I made in this form are true and correct to the best of my knowledge.
If accepted for the program, I agree:
(a) not to bring or invite any member of my family (except for the program whose period is one year or
more),
(b) to carry out such instructions and abide by such conditions as may be stipulated by both the
nominating government and the Japanese Government regarding the program,
(c) to follow the program, and abide by the rules of the institution or establishment that implements the
program,
(d) to refrain from engaging in political activity or any form of employment for profit or gain,
(e) to return to my home country at the end of the activities in Japan on the designated flight schedule
arranged by JICA,
(f) to discontinue the program if JICA and the applying organization agree on any reason for such
discontinuation and not to claim any cost or damage due to the said discontinuation.
(g) to consent to waive exercise of my copyright holder’s rights for documents or products those are
produced during the course of the project, against duplication and/or translation by JICA, as long as
they are used for the purposes of the program.
(h) to approve the privacy policy and the copyright policy mentioned in the Guidelines of Application.
JICA’s Information Security Policy in relation to Personal Information Protection
■ JICA will properly and safely manage personal information collected through this application form in
accordance with JICA’s privacy policy and the relevant laws of Japan concerning protection of
personal information and take protection measures to prevent divulgation, loss or damages of such
personal information.

■ Unless otherwise obtained approval from an applicant itself or there are valid reasons such as
disclosure under laws and ordinances, etc., and except for the following 1.-3., JICA will neither
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provide nor disclose personal information to any third party. JICA will use personal information
provided only for the purposes in the following 1.-3 and will not use for any purpose other than the
following 1.-3 without prior approval of an applicant itself.

1. To provide KCCP to the participants from developing countries.

2. To provide KCCP to the participants from developing countries under the Citizens’ Cooperation
Activities.

3. In addition to 1. and 2. above, if the government of Japan or JICA determines necessary in the
course of technical cooperation.

(i) to observe Japanese laws and ordinances during my stay, if I violate Japanese laws and ordinances,
I will return the total amount or a part of the expenditure required for the KCCP depending on the extent
of the violation.
(j) to understand that JICA does not assure issuance of Japan entry visa even after JICA decide to accept
me. I understand the Embassy of Japan will decide it according to necessary formalities upon the
submission of visa application from each participant.

Date: Signature:

Print Name:
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MEDICAL HISTORY

1. Present Medical Status

(a) Do you currently use any medicine or have regular medical checkup by a physician for
your illness?
[ ● ] No [ ] Yes: Name of illness ( ), Name of medicine ( )
If yes, please attach your doctor's letter (preferably, written in English) that
describes current status of your illness and agreement to join the program.
(b) Are you pregnant?
[ ● ] No [ ] Yes: Months of pregnancy ( months)
(c) Are you allergic to any medication or food?
[ ● ] No [ ] Yes: What are you allergic to? ( )
(d) Please indicate any needs arising from disabilities that might necessitate additional
support or facilities.
( N/A )
Note: Disability does not lead to exclusion of persons with disability from the program. However, upon the
situation, you may be directly inquired by the JICA official in charge for a more detailed account of your
condition.
2. Past Medical History
(a) Have you had any significant or serious illness?
[ ● ] No [ ] Yes: Please specify ( )
(b) Have you ever been a patient in a mental clinic or been treated by a psychiatrist?
[ ● ] No [ ] Yes: Please specify ( )
3. Other Medical Problems
If you have any medical problems that are not described above, please indicate below.

N/A

I certify that I have read the above instructions and answered all questions truthfully and
completely to the best of my knowledge.
I understand and accept that medical conditions resulting from an undisclosed pre-existing
condition may not be financially compensated by JICA and may result in termination of the
program.

Date Signature

Print Name