Form⑥

Request of Document Issue and Pledge

To Director General,
JICA 　　　　　　 INTERNATIONAL CENTER (BRANCH),
(JICA Program Officer in Charge Mr./Ms. )

I, (in block letter) CARLOS ALBANO MAROVE undersigned

PEACE participant, would like to inform you of my intention of the following (ticked ☑
below), and request you to issue the documents to prove that I’m a PEACE participant and
JICA is paying my living allowance. (奨学金給付証明書、経費支弁書)

D Number D-1405835

Nationality of the Participant MOZAMBICAN

Name of University HOKKAIDO UNIVERSITY

Program Period From 2014 Until 2017

□ 1. I intend to invite my family to stay with me during my stay in Japan, and request
documents issue so that my family can get the visa extension.
For inviting my family, I declare following (ticked ☑ below)
□Invitation of my family would not hinder the completion of the program.
□I am responsible for all expenses regarding the invitation and the life in Japan.
□I understand the circumstances of accepting foreigners, such as public and local
services, medical and educational circumstances for families in the local
community.
□I take responsibilities for all procedures and problems regarding the invitation of
my family including followings;
- Visa, accommodation, transportation and insurance etc.for my family
- Care for daily life and stress management of my family which stems from
different culture and circumstance.
- Medical care for my family including searching English-speaking doctors and
accompanying my family when visiting clinics/hospitals.
- Educational responsibility for my children including searching adequate
schools, carrying out entrance procedures, supporting their school life and so
on.
 Form⑥

The information of my family members I intend to invite and expected staying

period is as follows:
1. Name : 　　　Sex : F / M
Date of birth : 　 　　　　　
2. Name : 　　　Sex : F / M
Date of birth : 　 　　　　　
3. Name : 　　　Sex : F / M
Date of birth : 　 　　　　　

(Staying period)
1. Expected arrival date :
2. Expected departure date :

Agreement by the supervisor in University

I hereby agree on his/hers family invitation.
Date:(201 / / )
Name of supervisor:( 　　 )
Signature:( 　　 )

X 2. I intend to extend my visa until the completion of the program, and request
documents issue so that I can apply for visa extension.
Expiration Date of Current Visa: 28 NOV 2014

□ 3. Others: I WOULD LIKE TO KNOW IF JICA OR KIZUNA CAN SUPPORT US

TO SEND OUR BOOKS TO MOZAMBIQUE. IF NOT LET ME KNOW.

Date: 2016 / 09 / 06　

Signature: