{"id":3705,"date":"2022-07-06T14:23:51","date_gmt":"2022-07-06T21:23:51","guid":{"rendered":"https:\/\/seniors.nikkeiplace.org\/?page_id=3705"},"modified":"2026-04-15T16:53:32","modified_gmt":"2026-04-15T23:53:32","slug":"application-form","status":"publish","type":"page","link":"https:\/\/seniors.nikkeiplace.org\/ja\/application-form\/","title":{"rendered":"Application Form"},"content":{"rendered":"<p><\/p>\n\n\n\n<div class=\"wp-block-contact-form-7-contact-form-selector\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3787-o1\" lang=\"en-CA\" dir=\"ltr\" data-wpcf7-id=\"3787\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ja\/wp-json\/wp\/v2\/pages\/3705#wpcf7-f3787-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/ja\/wp-json\/wp\/v2\/pages\/3705#wpcf7-f3787-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3787\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_CA\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3787-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<style>\n.radio{\nvertical-align:middle;\nwhite-space: pre;\n}\n<\/style>\n<p><script>\ndocument.addEventListener( 'wpcf7mailsent', function( event ) {\n location = 'https:\/\/seniors.nikkeiplace.org\/thank-you\/';\n}, false );\n<\/script>\n<\/p>\n<h4><u>Personal Information<\/u>\n<\/h4>\n<p><\/br>\n<\/p>\n<div style=\"display:flex\">\n\t<h6>Note that all fields with this symbol are required:\n\t<\/h6>\n\t<p><label style=\"color:red\">*<\/label>\n\t<\/p>\n<\/div>\n<h4><u>Name<\/u>\n<\/h4>\n<p><label>\u540d<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"first-name\" style=\"text-transform:none\" required \/>\n<\/p>\n<p><label>\u6c0f<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"last-name\" style=\"text-transform:none\" \/>\n<\/p>\n<h4><u>Home<\/u>\n<\/h4>\n<p><label>Address:<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"address\" style=\"text-transform:none\" required \/>\n<\/p>\n<p><label>City:<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"city\" style=\"text-transform:none\" required \/>\n<\/p>\n<p><label>Province:<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"province\" style=\"text-transform:none\" required \/>\n<\/p>\n<p><label>Postal Code:<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"postal-code\" style=\"text-transform:none\" required \/>\n<\/p>\n<h4><u>Contact Information<\/u>\n<\/h4>\n<p><label>Phone Number:<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"tel\" name=\"phone\" style=\"text-transform:none\" required \/>\n<\/p>\n<p><label>Alternate Phone Number:<\/label><br \/>\n<input type=\"tel\" name=\"alt-phone\" style=\"text-transform:none\" required \/>\n<\/p>\n<p><label>\u30a4\u30fc\u30e1\u30fc\u30eb<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"email\" name=\"email\" style=\"text-transform:none\" required \/>\n<\/p>\n<h4><u>Status<\/u>\n<\/h4>\n<p><label>What is your employment status?<\/label><label style=\"color:red\"><\/label><br \/>\n<label class=\"radio\">Student <input type=\"radio\" name=\"employment\" value=\"Student\" class=\"radio\" required \/> <\/label><br \/>\n<label class=\"radio\">Employed <input type=\"radio\" name=\"employment\" value=\"Employed\" class=\"radio\" required \/><\/label><br \/>\n<label class=\"radio\">Unemployed <input type=\"radio\" name=\"employment\" value=\"Unemployed\" class=\"radio\" required \/> <\/label><br \/>\n<label class=\"radio\">Retired <input type=\"radio\" name=\"employment\" value=\"Retired\" class=\"radio\" required \/><\/label>\n<\/p>\n<p><label>\u30ab\u30ca\u30c0\u3067\u306e\u8eab\u5206\u72b6\u6cc1<\/label><label style=\"color:red\">*<\/label><br \/>\n<select name=\"status\">\n<option value=\"Citizen\">\u30ab\u30ca\u30c0\u56fd\u6c11\n<\/option><option value=\"Permanent Resident\">\u6c38\u4f4f\u8005\n<\/option><option value=\"Working Holiday Visa\">Working Holiday Visa\n<\/option><option value=\"Work Permit\">Work Permit\n<\/option><option value=\"Student Visa\">Student Visa\n<\/option><\/select>\n<\/p>\n<p><label>If you are here on a visa, what is the termination date of your visa?<\/label><br \/>\n<input type=\"date\" name=\"visa-termination\" \/>\n<\/p>\n<h4><u>Emergency Contact<\/u>\n<\/h4>\n<p><label>Name of Emergency Contact<\/label><br \/>\n<input type=\"text\" name=\"emergency-contact-name\" style=\"text-transform:none\" \/>\n<\/p>\n<p><label>Emergency Contact Phone Number<\/label><br \/>\n<input type=\"tel\" name=\"emergency-contact-number\" \/>\n<\/p>\n<h4><u>Language Skills<\/u>\n<\/h4>\n<p><label>How fluent are you English:<\/label><label style=\"color:red\">*<\/label><br \/>\n<label>Speaking: <\/label><br \/>\n<select name=\"fluency-speaking-eng\">\n<option value=\"Fluent\">Fluent\n<\/option><option value=\"Semi Fluent\">Semi-Fluent\n<\/option><option value=\"Conversation Level\">Conversation Level\n<\/option><option value=\"Basic Understanding\">Basic Understanding\n<\/option><option value=\"None\">None\n<\/option><\/select>\n<\/p>\n<p><label>Writing: <\/label><br \/>\n<select name=\"fluency-writing-eng\">\n<option value=\"Fluent\">Fluent\n<\/option><option value=\"Semi Fluent\">Semi-Fluent\n<\/option><option value=\"Conversation Level\">Conversation Level\n<\/option><option value=\"Basic Understanding\">Basic Understanding\n<\/option><option value=\"None\">None\n<\/option><\/select>\n<\/p>\n<p><label>Reading: <\/label><br \/>\n<select name=\"fluency-reading-eng\">\n<option value=\"Fluent\">Fluent\n<\/option><option value=\"Semi Fluent\">Semi-Fluent\n<\/option><option value=\"Conversation Level\">Conversation Level\n<\/option><option value=\"Basic Understanding\">Basic Understanding\n<\/option><option value=\"None\">None\n<\/option><\/select>\n<\/p>\n<p><label>How fluent are you Japanese:<\/label><label style=\"color:red\">*<\/label><br \/>\n<label>Speaking: <\/label><br \/>\n<select name=\"fluency-speaking-jap\">\n<option value=\"Fluent\">Fluent\n<\/option><option value=\"Semi Fluent\">Semi-Fluent\n<\/option><option value=\"Conversation Level\">Conversation Level\n<\/option><option value=\"Basic Understanding\">Basic Understanding\n<\/option><option value=\"None\">None\n<\/option><\/select>\n<\/p>\n<p><label>Writing: <\/label><br \/>\n<select name=\"fluency-writing-jap\">\n<option value=\"Fluent\">Fluent\n<\/option><option value=\"Semi Fluent\">Semi-Fluent\n<\/option><option value=\"Conversation Level\">Conversation Level\n<\/option><option value=\"Basic Understanding\">Basic Understanding\n<\/option><option value=\"None\">None\n<\/option><\/select>\n<\/p>\n<p><label>Reading: <\/label><br \/>\n<select name=\"fluency-reading-jap\">\n<option value=\"Fluent\">Fluent\n<\/option><option value=\"Semi Fluent\">Semi-Fluent\n<\/option><option value=\"Conversation Level\">Conversation Level\n<\/option><option value=\"Basic Understanding\">Basic Understanding\n<\/option><option value=\"None\">None\n<\/option><\/select>\n<\/p>\n<h4><u>Availability<\/u>\n<\/h4>\n<h5>Please Click the Checkboxes Corresponding to when you are Available. This section is required\n<\/h5>\n<table border=\"1\" style=\"text-align:center\">\n\t<tr>\n\t\t<th>\n\t\t\t<p>Day of the Week\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Morning\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Afternoon\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Evening\n\t\t\t<\/p>\n\t\t<\/th>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Monday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"monday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"monday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"monday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"monday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"monday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"monday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Tuesday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"tuesday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"tuesday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"tuesday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"tuesday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"tuesday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"tuesday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Wednesday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"wednesday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"wednesday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"wednesday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"wednesday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"wednesday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"wednesday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Thursday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"thursday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"thursday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"thursday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"thursday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"thursday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"thursday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Friday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"friday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"friday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"friday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"friday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"friday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"friday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Saturday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"saturday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"saturday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"saturday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"saturday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"saturday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"saturday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Sunday\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"sunday-morning\" value=\"not available\" \/><input type=\"checkbox\" name=\"sunday-morning\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"sunday-afternoon\" value=\"not available\" \/><input type=\"checkbox\" name=\"sunday-afternoon\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" name=\"sunday-evening\" value=\"not available\" \/><input type=\"checkbox\" name=\"sunday-evening\" value=\"available\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<th>\n\t\t<\/th>\n\t\t<th>\n\t\t<\/th>\n\t\t<th>\n\t\t<\/th>\n\t<\/tr>\n<\/table>\n<p><\/br>\n<\/p>\n<p><label>How long would you like to volunteer with us? (minimum six months)<\/label><label style=\"color:red\">*<\/label><br \/>\n<label>Months:<\/label><br \/>\n<input type=\"text\" name=\"months\" style=\"text-transform\" \/>\n<\/p>\n<p><label>Hours per Week:<\/label><br \/>\n<input type=\"text\" name=\"hours\" style=\"text-transform\" \/>\n<\/p>\n<h4><u>Volunteer Interests<\/u>\n<\/h4>\n<h5>Please Select which Volunteer Positions you are Interested In. Check the boxes in row containing positions you are interested in\n<\/h5>\n<table border=\"1\" style=\"text-align:center\">\n\t<tr>\n\t\t<th>\n\t\t\t<p>Department\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Position\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Choice\n\t\t\t<\/p>\n\t\t<\/th>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nikkei Home\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Reception Desk\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"reception-desk\" \/><input type=\"checkbox\" name=\"reception-desk\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nikkei Home\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>One-on-One\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"one-on-one\" \/><input type=\"checkbox\" name=\"one-on-one\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nikkei Home\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Recreation Program Help\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"recreation-program\" \/><input type=\"checkbox\" name=\"recreation-program\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nikkei Home\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Special Events Help\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"special-events\" \/><input type=\"checkbox\" name=\"special-events\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nikkei Home\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Driver\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"driver\" \/><input type=\"checkbox\" name=\"driver\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Outreach Project\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Community Program\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"kui\" \/><input type=\"checkbox\" name=\"kui\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Outreach Project\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Dementia Friendly Community Program\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"hidden\" value=\"No\" name=\"iki\" \/><input type=\"checkbox\" name=\"iki\" value=\"Yes\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<th>\n\t\t<\/th>\n\t\t<th>\n\t\t<\/th>\n\t\t<th>\n\t\t<\/th>\n\t<\/tr>\n<\/table>\n<p><\/br>\n<\/p>\n<p><label>Why are you interested in the positions you have marked?<\/label><label style=\"color:red\">*<\/label><br \/>\n<input type=\"text\" name=\"reason\" style=\"text-transform:none\" \/>\n<\/p>\n<h4><u>Experience<\/u>\n<\/h4>\n<p><label>Do you play any instruments?<\/label><br \/>\n<input type=\"text\" name=\"instrument\" style=\"text-transform:none\" \/>\n<\/p>\n<p><label>Do you like to sing?<\/label><br \/>\n<input type=\"text\" name=\"sing\" style=\"text-transform:none\" \/>\n<\/p>\n<p><label>What type of music do you enjoy<\/label><br \/>\n<input type=\"text\" name=\"enjoy\" style=\"text-transform:none\" \/>\n<\/p>\n<p><label>What type of art do you enjoy<\/label><br \/>\n<input type=\"text\" name=\"arts\" style=\"text-transform:none\" \/>\n<\/p>\n<p><label>Have you ever worked with seniors before?<\/label><br \/>\n<label class=\"radio\">\u306f\u3044 <input type=\"radio\" value=\"yes\" name=\"work-seniors\" class=\"radio\" \/><\/label><br \/>\n<label class=\"radio\">\u3044\u3044\u3048 <input type=\"radio\" value=\"no\" name=\"work-seniors\" class=\"radio\" \/><\/label>\n<\/p>\n<p><label>Please provide two references<\/label><label style=\"color:red\">*<\/label>\n<\/p>\n<table style=\"text-align:center\">\n\t<tr>\n\t\t<th>\n\t\t\t<p>Name\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Occupation\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>Relationship\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>\u96fb\u8a71\u756a\u53f7\n\t\t\t<\/p>\n\t\t<\/th>\n\t\t<th>\n\t\t\t<p>\uff72\uff70\uff92\uff70\uff99\n\t\t\t<\/p>\n\t\t<\/th>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><input type=\"text\" name=\"ref1-name\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"text\" name=\"ref1-occupation\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"text\" name=\"ref1-relationship\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"tel\" name=\"ref1-phone\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"email\" name=\"ref1-email\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p><input type=\"text\" name=\"ref2-name\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"text\" name=\"ref2-occupation\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"text\" name=\"ref2-relationship\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"tel\" name=\"ref2-phone\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p><input type=\"email\" name=\"ref2-email\" style=\"text-transform:none\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<th>\n\t\t<\/th>\n\t\t<th>\n\t\t<\/th>\n\t\t<th>\n\t\t<\/th>\n\t<\/tr>\n<\/table>\n<p><\/br>\n<\/p>\n<p><label class=\"radio\">Do you agree to a criminal record check?<\/label><label style=\"color:red\">*<\/label>\n<\/p>\n<h6>The criminal record search is limited to the specified offences listed in the Criminal Records Review Act for the purpose of working with vulnerable adults\n<\/h6>\n<p><input type=\"hidden\" value=\"No\" name=\"record\" \/><label>\u306f\u3044 <input type=\"checkbox\" name=\"record\" value=\"Yes\" \/><\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Application\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"ja\"\/><\/form>\n<\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"Personal Information Note that all fields with this symbol are required: * Name First Name:* Last Name:* Home Address:* City:* Province:* Postal Code:* Contact Information Phone Number:* Alternate Phone Number: Email:* Status What is your employment status? Student Employed Unemployed Retired What is your status in Canada?* Citizen Permanent Resident Working Holiday Visa Work Permit [...]","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-3705","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Application Form - Nikkei Place Seniors<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/seniors.nikkeiplace.org\/ja\/application-form\/\" \/>\n<meta property=\"og:locale\" content=\"ja_JP\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Application Form - 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