《在留資格認(rèn)定證明書交付申請(qǐng)書》

1、別記第六號(hào)三様式（第六條二関係）申請(qǐng)人等作成用1Forapplicant,part1日本國(guó)政府法務(wù)省MinistryofJustice,GovernmentofJapan在留資格認(rèn)定証明書交付申請(qǐng)書APPLICATIONFORCERTIFICATEOFELIGIBILITY東京入國(guó)管理局長(zhǎng)殿TotheDirectorGeneralofRegionalImmigrationBureau出入國(guó)管理及難民認(rèn)定法第7條020規(guī)定基舍,次O七指同法第7條第1項(xiàng)第2號(hào)怎掲廳6條件適合LXV6旨O証明書O交付總申請(qǐng)LToPursuanttotheprovisionsofArticle7-2oftheImmi

2、gration-ControlandRefugee-RecognitionAct,IherebyapplyforthecertificateshowingeligibilityfortheconditionsprovidedforinArticle7,Paragraph1,Item2ofthesaidAct.Photo1國(guó)籍Nationality2生年月日Dateofbirth年YearFamilyname月日MonthDayGivenname3氏名(漢字)NameinChinesecharacter4(英字)NameinEnglish101112141617181920男女Male/Fema

3、le性別Sex職業(yè)Occupation日本連絡(luò)先AddressinJapan電話番號(hào)TelephoneNo.0255出生地Placeofbirth8本國(guó)6居住地Hometown/city新潟市西區(qū)五十嵐20町8050番地新潟大學(xué)國(guó)際課6配偶者有無(wú)有無(wú)MaritalstatusMarried/Single2627632旅券（1）番號(hào)PassportNumber_入國(guó)目的（次該當(dāng)選攜帯電話番號(hào)CellularphoneNo.(2)有効期限D(zhuǎn)ateofexpirationYearMonth日DayI教授教育口J蕓術(shù)文化活動(dòng)Professor/InstructorArtist/CulturalActi

4、vitiesL報(bào)道研究(転勤)企業(yè)內(nèi)転勤Journalist/Researcher(Transferee)/Intra-companyTransfereePurposeofentry:checkoneofthefollowingsK宗教ReligiousActivitiesM投資経営Investor/BusinessManagerN研究技術(shù)人文知識(shí)國(guó)際業(yè)務(wù)技能特定活動(dòng)(/口)Researcher/Engineer/SpecialistinHumanities/InternationalServices/SkilledLabor/DesignatedActivities(a/b)Y技能実習(xí)1號(hào)P

5、留學(xué)TechnicalInternTraining(i)StudentR家族滯在特定活動(dòng)(八)特定活動(dòng)(EPA家族)Dependent/DesignatedActivities(c)/DependentofEPAT日本人O配偶者等永住者O配偶者等定住者SpouseorChildofJapaneseNational/SpouseorChildofPermanentResident/Long-TermResident入國(guó)予定年月日年月日DateofentryYearMonthDay滯在予定期間Intendedlengthofstay査証申請(qǐng)予定地Intendedplacetoapplyforvis

6、a過(guò)去O出入國(guó)歴有無(wú)Pastentryinto/departurefromJapanYes/No(上記有總選択L亡場(chǎng)合)(FillinthefollowingswhentheanswerisYes)回?cái)?shù)回直近O出入國(guó)歴年月time(s)(ThelatestentryfromYear1315上陸予定港Portofentry同伴者有無(wú)Accompanyingpersons,ifanyMonth日力巧Dayto有Yes/NoYearO興行EntertainerQ研修TraineeU巾他Others無(wú)八、Month日Day犯罪總理由O總含住。)Criminalrecord(inJapan/overse

7、as)有(具體的內(nèi)容)無(wú)Yes(Details)退去強(qiáng)制又肚出國(guó)命有Departurebydeportation/deartureorderYes/(上記有總選択L亡場(chǎng)合)回?cái)?shù)回(FillinthefollowingswhentheanswerisYes)time(s)回?cái)?shù)無(wú)八、No直近送還歴ThelatestdeparturebydeportationYearNoMonth日Day続柄Relationship氏名Name生年月日Dateofbirth國(guó)籍Nationality同居予定Intendedtoresidewithapplicantornot勤務(wù)先通學(xué)先Placeofemployme

8、nt/school外國(guó)人登録証明書番號(hào)Alienregistrationcertificatenumber電、壇Yes/No電、壇Yes/No在日親族(父母配偶者子兄弟姉妹卞及廠同居者FamilyinJapan(Father,Mother,Spouse,Son,Daughter,Brother,Sisterorothers)orco-residents電、w壇Yes/No電、W壇Yes/No(注)裏面參照上，申請(qǐng)Q必要卞書類總作成下$V0Note:Pleasefillinformsrequiredforapplication.(Seenotesonreverseside.)申請(qǐng)人等作成用2P(

9、留學(xué))Forapplicant,part P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility申請(qǐng)人等作成用2P(留學(xué))Forapplicant,part #P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility21通學(xué)先Placeofstudy名稱新潟大學(xué)Nameofschool所在地新潟市西區(qū)五十嵐2町8050番地Address電話番號(hào)025262632TelephoneNo.22修學(xué)年數(shù)(小學(xué)校最終學(xué)歴)Totalperiodofeducation(fromelementaryschooltolastins

10、titutionofeducation)年Years23最終學(xué)歴(又肚在學(xué)中學(xué)校)在籍狀況口Registeredenrollment大學(xué)院(博士)Doctor高等學(xué)校Seniorhighschool學(xué)校名Nameoftheschool卒業(yè)Graduated大學(xué)院(修士)Master中學(xué)校JuniorhighschoolEducation(lastschoolorinstitution)orpresentschool在學(xué)中Inschool休學(xué)中Temporaryabsence大學(xué)Bachelor乞勸也(Others中退Withdrawal短期大學(xué)Juniorcollege専門學(xué)校Collegeo

11、ftechnology)24(3)卒業(yè)又肚卒業(yè)見込族年月曰Dateofgraduationorexpectedgraduation年Year月Month日Day日本語(yǔ)能力(専修學(xué)校又怎各種學(xué)校本語(yǔ)教育以外教育總受廿召場(chǎng)合O記入)Japaneselanguageability(Fillinthefollowingswhentheapplicantplanstostudyatadvancedvocationalschoolorvocationalschool(exceptJapaneselanguage)日本語(yǔ)能力試験【級(jí)合格】JapaneselanguageproficiencytestPass

12、edLevelBJT匕歹木滅日本語(yǔ)能力亍滅卜【BJTBusinessJapaneseProficiencyTest日本語(yǔ)教育總受療尢教育機(jī)関及廠期間機(jī)関名Organization日本留學(xué)試験(読解聴解聴読解合計(jì)點(diǎn))【】ExaminationforJapaneseUniversity(EJU)(exceptwriting點(diǎn)】pointsOrganizationandperiodtohavereceivedJapaneselanguageeducation點(diǎn)】points】期間：Periodfrom乞他：Others年Year月Month力巧to年Year月Month申請(qǐng)人等作成用2P(留學(xué))Fo

13、rapplicant,part P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility申請(qǐng)人等作成用2P(留學(xué))Forapplicant,part #P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility25日本語(yǔ)學(xué)習(xí)歴(高等學(xué)校教育總受療召場(chǎng)合人記入)Japaneseeducationhistory(Fillinthefollowingswhentheapplicantplanstostudyinhighschool)日本語(yǔ)教育又肚日本語(yǔ)0孟召教育總受療尢教育機(jī)関及廠期間Organizationandperiod

14、tohavereceivedJapaneselanguageeducation/receivededucationbyJapaneselanguage機(jī)関名Organization申請(qǐng)人等作成用2P(留學(xué))Forapplicant,part #P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility申請(qǐng)人等作成用2P(留學(xué))Forapplicant,part #P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility期間：Periodfrom年Year月力巧Monthto年Year月求rMonth26滯在費(fèi)支弁方法等M

15、ethodofsupporttomeettheexpenseswhileinJapan(1)支弁方法及曠月平均支弁額Methodofsupportandanamountofsupportpermonth(average)本人負(fù)擔(dān)円SelfYen外國(guó)力5送金Remittancefromabroad円Yen外國(guó)力5攜行Carryingfromabroad(攜行者Who円Yen攜行時(shí)期When在日経費(fèi)支弁者負(fù)擔(dān)SupporterinJapan乞他Others円Yen円Yen奨學(xué)金Scholarship円Yen(2)経費(fèi)支弁者氏名Name住所AddressSupporter電話番號(hào)TelephoneN

16、o.職業(yè)(勤務(wù)先名稱)電話番號(hào)Occupation(placeofemployment)TelephoneNo.年収円AnnualincomeYen申請(qǐng)人等作成用3P(留學(xué))Forapplicant,part P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility申請(qǐng)人七関係(上記(i)r外國(guó)卞送金，外國(guó)卞攜行又肚在日経費(fèi)支弁者負(fù)擔(dān)總選択。上場(chǎng)合広記入)Relationshipwiththeapplicant(Checkoneofthefollowingswhenyouranswertothequestion26(1)isremittancefromab

17、road,carryingfromabroadorsupporterinJapan)夫妻HusbandWife兄弟姉妹Brother/Sister父母祖父FatherMotherGrandfather叔父(伯父)叔母(伯母)Uncle/Aunt祖母口養(yǎng)父GrandmotherFosterfather受入教育機(jī)関Educationalinstitution養(yǎng)母Fostermother友人知人Friend/Acquaintance友人知人親族口取引関係者現(xiàn)地企業(yè)等職員Relativeoffriend/acquaintanceBusinessconnection/Personneloflocalen

18、terprise取引関係者現(xiàn)地企業(yè)等職員親族口乞他(Relativeofbusinessconnection/personneloflocalenterpriseOthers(4)奨學(xué)金支給機(jī)関(上記(i)r奨學(xué)金總選択。尢場(chǎng)合人記入)Organizationwhichprovidescholarship(Checkoneofthefollowingwhentheanswertothequestion26(1)isscholarship)外國(guó)政府日本國(guó)政府地方自治體ForeigngovernmentJapanesegovernmentLocalgovernment公益社団法人又肚公益財(cái)団法人(

19、)口乞他(PublicinterestincorporatedassociationorpublicinterestincorporatedfoundationOthers27卒業(yè)後予定Plansaftergraduation帰國(guó)日本r進(jìn)學(xué)ReturntohomecountryEnterschoolofhighereducationinJapan日本r就職口乞勿也(FindworkinJapanOthers28申請(qǐng)人又肚法定代理人若法第7條02第2項(xiàng)人規(guī)定代理人Applicant,legalrepresentativeortheproxyinaccordancewiththeprovision

20、ofArticle7-2,Paragraph2.(2)本人七関係Relationshipwiththeapplicant新潟市西區(qū)五十嵐2町8050番地受入大學(xué)職員氏名Name住所Address攜帯電話番號(hào)CellularPhoneNo.電話番號(hào)TelephoneNo.以上記載內(nèi)容總事実七相違厲9求乜人oIherebydeclarethatthestatementgivenaboveistrueandcorrect.申請(qǐng)人(法定代理人等)署名/申請(qǐng)書作成年月日Signatureoftheapplicant(legalrepresentativeortheproxy)/Dateoffilling

21、inthisform新潟大學(xué)年Year月Month日Day注意Attention申請(qǐng)書作成後申請(qǐng)記載內(nèi)容広変更力生匕比場(chǎng)合，申請(qǐng)人(法定代理人等)力変更箇所總訂正署名Incaseswheredescriptionshavechangedafterfillinginthisapplicationformupuntilsubmissionofthisapplication,theapplicant(legalrepresentativeortheproxy)mustcorrectthepartconcernedandsigntheirname.29申請(qǐng)取次者等(申請(qǐng)取次者弁護(hù)士行政書士等16申請(qǐng)場(chǎng)

22、合人記入)Agentorother(incaseofanagent,lawyer,administrativescrivenerorother)氏名(2)住所NameAddress(3)所屬機(jī)関等Organizationtowhichtheagentbelongs電話番號(hào)TelephoneNo.所屬機(jī)関等作成用1P(留學(xué))Fororganization,part P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility入學(xué)外國(guó)人氏名Nameoftheforeignertoenterschool通學(xué)先(1)學(xué)校名NameofSchool所在地Address電

23、話番號(hào)TelephoneNo.PlaceofStudy新潟大學(xué)新潟市西區(qū)五十嵐2町8050番地0252627632(3)學(xué)校種類Classificationofschool大學(xué)University各種學(xué)校(日本語(yǔ)教育以外)大學(xué)院GraduateschoolVocationalschool(exceptJapaneselanguageschool)高等學(xué)校乞O他(SeniorhighschoolOthers授業(yè)形態(tài)Typeofclass晝間制口晝夜間制DayclassesDay-Eveningclasses短期大學(xué)口専修學(xué)校(日本語(yǔ)教育以外)JuniorcollegeAdvancedvocati

24、onalschool(exceptJapaneselanguageschool)日本語(yǔ)教育機(jī)関Japaneselanguageinstitution夜間制Eveningclasses所屬機(jī)関等作成用1P(留學(xué))Fororganization,part P(Student)在留資格認(rèn)定証明書用Forcertificateofeligibility通信制(単位o部總匕、滬才又肚彳夕一木處等0孟召教育人列取得場(chǎng)合總含拭)Correspondencecourse(includingcasesreceivingcreditsforeducationviavideoorinternet)教育總受療召校舎O

25、所在地同上Addressoftheschoolwheretheapplicantwillbeeducated電話番號(hào)0252627632TelephoneNo.(6)生活指導(dǎo)擔(dān)當(dāng)者名(通學(xué)先力専修學(xué)校又肚各種學(xué)校場(chǎng)合人記入)NameoftheresidentadviserinJapan(incasethattheplaceofstudyisanadvancedvocationalschoolorvocationalschool)有無(wú)Yes/No學(xué)校法人Educationalfoundation)(7)學(xué)生交換計(jì)畫有無(wú)及當(dāng)該計(jì)畫策定主體(通學(xué)先力高等學(xué)校場(chǎng)合人記入)Istheapplicantp

26、articipatinginastudentexchangeprogram?Whichorganizationisinchargeofthatprogram?(whentheplaceofstudyisseniorhighschool)獨(dú)立行政法人口國(guó)立大學(xué)法人IncorporatedadministrativeagencyNationaluniversitycorporation乞他(Others國(guó)又肚地方公共団體O機(jī)関Nationalorlocalgovernment公益社団法人又肚公益財(cái)団法人Publicinterestincorporatedassociationorpublicint

27、erestincorporatedfoundation入學(xué)年月曰年月日DateofentraneeYearMonthDay週間授業(yè)時(shí)間Lessonhoursperweek在籍區(qū)分Registration大學(xué)院(博士)Doctor大學(xué)(學(xué)部生)Undergraduatestudent大學(xué)(別科生)University(Japaneselanguagecoursestudent)短期大學(xué)(學(xué)部學(xué)科生)Juniorcollege(Regularstudent)高等専門學(xué)校Higheradvancedprofessionalschool専修學(xué)校(専門課程)Advancedvocationalschoo

28、l(Specializedcourse)各種學(xué)校Vocationalschool日本語(yǔ)教育機(jī)関(専修學(xué)校専門課程)Japaneselanguageinstitution(Advancedvocationalschoolofspecializedcourse)日本語(yǔ)教育機(jī)関3他)口高等學(xué)校Japaneselanguageinstitution(Others)Seniorhighschool大學(xué)院(修士)Master大學(xué)(聴講生科目等履修生)University(Auditorelectivecoursestudent)大學(xué)院(研究生)Graduateschool(Researchstudent)

29、大學(xué)(研究生)University(Researchstudent)短期大學(xué)(聴講生科目等履修生)Juniorcollege(Auditorelectivecoursestudent)短期大學(xué)(別科生)Juniorcollege(Japaneselanguagecoursestudent)専修學(xué)校(高等課程)Advancedvocationalschool(Highercourse)専修學(xué)校(一般課程)Advancedvocationalschool(Generalcourse)日本語(yǔ)教育機(jī)関(準(zhǔn)備教育課程)Japaneselanguageinstitution(Preparatorycour

30、ses)他()Others法學(xué)経済學(xué)政治學(xué)商學(xué)経営學(xué)文學(xué)LawEconomicsPoliticsCommercialscienceBusinessadministrationLiterature語(yǔ)學(xué)社會(huì)學(xué)歴史學(xué)心理學(xué)教育學(xué)蕓術(shù)學(xué)LinguisticsSociologyHistoryPsychologyEducationScienceofart他人文社會(huì)科學(xué)（)理學(xué)化學(xué)工學(xué)Others(culturalscience/socialscience)ScienceChemistryEngineer農(nóng)學(xué)水産學(xué)薬學(xué)醫(yī)學(xué)歯學(xué)AgricultureFisheriesPharmacyMedicineDentistry乞他自然科學(xué)(Others(naturalscience)學(xué)部課程Faculty/Course(5T大學(xué)院(博士)大學(xué)(研究生)，短期大學(xué)(學(xué)部學(xué)科生)，短期大學(xué)(聴講生科目等履修生)場(chǎng)合記入)(Checkoneo