1.  Name:   

2.  Email Address:   

3.  Telephone Number:   

4.  Preferred Contact Time (Japanese time):

          Early Morning

          Morning

          Afternoon

          Evening

          Night

5.  Current Location:   

6.  Available for Interview (in Hiroshima or via Skype):  ----- Yes No     If YES, from when (month/day):    

7.  Age:    (we welcome both younger and older teachers)

8.  Nationality:    --------------- Canadian British Irish Australian U.S.A. New Zealand South African Filipino Other

9.  Current Visa Status:    ------------------------ None Visitor Permit (Tourist) Working Holiday Working: Humanities Working: Other Spouse Student     Valid until:   

10.  Gender:    ----- Male Female

11.  Marital Status:    --------------- Single With partner

12.  Available from:    --------------- Immediately After VISA organized 1 week 2 weeks 3 weeks 1 month 2 months 3 months+

13.  Available for:    --------------- 1 month or less Summer holiday 3 months 6 months 12 months 18 months 2 years+

14.  Experience Teaching English (full time equivalent):    --------------- None less than 40 hours 40 hours - 3 months 3 - 6 months 6 - 12 months 1 - 2 years 2 - 3 years 3+ years

15.  Highest Education:    --------------- High School Certificate 1 - 2 year university/college 3 year degree 4 year degree Higher degree     Specialty:   

16.  Teaching Certificates:    --------------- None 1 - 2 week course 2 - 3 week course CELTA DELTA Masters (TEFL or related) Other     Specify:   

17.  Driver's License:    ----- Japanese International (Car) International (Car/Motorcycle)

18.  Experience Living Abroad:    --------------- Less than 1 month 1 - 3 months 3 - 6 months 6+ months

19.  Experience Living in Japan:    --------------- None Less than 1 month 1 - 6 months 6 - 12 months 1-2 years 2+ years

20.  Japanese proficiency:    --------------- None Basic Conversational Can read 200+ kanji JLPT 2+

21.  Teaching Preference:    ----- Pre-school Elementary Junior High Adults Business people

22.  Minimum Salary (Yen):    ---------------------- Board only 133,000 (US$1330) 150,000 (US$1500) 175,000 (US$1750) 200,000 (US$2000) 225,000 (US$2250) 250,000 (US$2500) 275,000 (US$2750) 300,000+ (US$3000)

23.  Preferred Location:    Inner-city    Suburbs    Rural

24.  What do you like to do in your free time?

25.  What do you think this job involves?

26.  What do you hope to be doing in 5 years?

27.  Other comments:

We will try to respond to your application as soon as possible.  If you are unsuccessful on this occasion, it may be due to a specific need at a particular time.  Please do not hesitate to reapply.  If we can help with your job seeking efforts in any way, please let us know.  Thank you very much for you time and patience.