別記第六号の三様式（第六条の二関係）
申請人等作成用 １

日本国政府法務省
Ministry of Justice, Government of JapanFor applicant, part 1

No need to attach
your photo here!

在 留 資 格 認 定 証 明 書 交 付 申 請 書
APPLICATION FOR CERTIFICATE OF ELIGIBILITY

法
務大臣
殿
If youa personwith dual nationality,
Toare
the Ministerof Justiceplease write one nationality on yourpassport that you will use in entering
Write EXACTLY THE SAME NAME
出入国管理及び難民認定法第７条の２の規定に基づき，次のとおり同法第７条第１項第２号にJapan.
IN ALPHABET as in your PASSPORT.
掲げる条件に適合している旨の証明書の交付を申請します。
Pleasewrite "China(Hong Kong)" if you
Family Name should come first.
to theKong.
provisions of Article 7-2 of the Immigration
and Refugee
Recognition
arePursuant
from Hong
Write Control
your Middle
Nameas well. Act, I hereby apply forthe certificate showing eligibility for the conditions provided
7, Paragraph
1, Item 2 of the said Act.
Please fordoinnot
use umlauts.
1 国 籍・地 域
3 氏 名

Family name男

4 性 別・MaleSex

7 職 業

Occupation/

女

5 出生地Female

有MarriedDay無・Single/

Please do NOT change the informationof No. 9. Address, Telephone No. andcellular phone No. are those of Keio

慶應義塾大学学生部学事グループ法務研究科担当 東京都港区三田2－15－45
If you are currently applying for

03-5427-1778 a passport, please write携帯電話番号

Telephone No.

"Professor""Instructor"□ Ｌ 「企業内転勤」"Artist""Nursing Care"□ M 「経営・管理」□ Ｎ 「研究」"Business Manager”"Researcher""Engineer / Specialist in Humanities / International Services""Technical Intern Training ( i )""Designated Activities (Graduate from a university in Japan)"■ Ｐ 「留学」□ Ｒ「特定活動（本邦大卒者家族）」

Date of entryDay

16 査証申請予定地□ Ｕ 「その他」
OthersNarita Airport
有 ・ 無Yes/NoParis, France

Intended place to apply for visa

Be sure to circle "Yes" or
17 過去の出入国歴

If you have visited Japan before, write down the number oftimes you visited Japan and the date of last entry period
CORRECTLY.

有 ・ 無

Past entry into / departure from Japan
Yes / No
（上記で『有』を選択した場合） (Fill in the followings when the answer is "Yes")

1

A tentative port of entry isPort of entry

15 同伴者の有無
Accompanying
if any or
Be sure topersons,circle "Yes"

6 months

Intended length of stay

"Dependent""Designated Activities(Dependent of Gradutate from a university in Japan)""Designated Activities(Dependent of EPA)"

accepted.
If you will stay for a semester,□ Ｔ 「日本人の配偶者等」A tentative date is□Ｔ「永住者の配偶者等」□ Ｔ「定住者」
You don't have to enter"Spouse or Child of Japanese National""Spouse or Child
Resident""Long Term Resident"
fill inof Permanent"6 months."□ 「高度専門職（1号イ）」 Japan on the date.
□ 「高度専門職（1号ロ）」□ 「高度専門職（1号ハ）」If you will stay for two"Highly Skilled Professional(i)(a)""Highly Skilled Professional(i)(b)"semesters, fill in "12 months." "Highly Skilled Professional(i)(c)"
年月
12 入国予定年月日
13 上陸予定港
2021
315 日
YearMonth
14 滞在予定期間□ Ｒ 「家族滞在」"Technical Intern Training ( ⅲ )"□ Ｒ「特定活動（EPA家族）」"Designated Activities (Dependent of Researcher or IT engineer of a designated org)""Trainee"□ Y 「技能実習（3号）」"Technical Intern Training ( ⅱ )"□ Ｒ 「特定活動（研究活動等家族）」□ Ｑ 「研修」"Student""Entertainer"□ Y 「技能実習（2号）」"Journalist"□ Ｎ「特定活動（本邦大学卒業者）」□ Ｏ 「興行」"Specified Skilled Worker ( ⅱ ) "□ Y 「技能実習（1号）」

Day□ Ｎ 「技術・人文知識・国際業務」"Designated Activities ( Researcher or IT engineer of a designated org)"□ Ｖ「特定技能（2号）」"Specified Skilled Worker ( i ) "

日X

Month

□ Ｌ「報道」"Religious Activities"□ Ｎ「特定活動（研究活動等）」"Skilled Labor"□ Ｖ「特定技能（1号）」□ Ｋ 「宗教」"Cultural Activities""Researcher (Transferee)"□ Ｎ 「技能」

月X

Year

Purpose of entry: check one of the followings□ Ｊ 「文化活動」□ Ｌ 「研究（転勤）」"Intra-company Transferee"

年

20XX

Date of expiration

11 入国目的 （次のいずれか該当するものを選んでください。）□ Ｉ 「教授」□ Ｉ 「教育」□ Ｊ 「芸術」□ Ｎ 「介護」(2)有効期限MQ1234XXXX

Number――――Ｎ／Ａ――――

Cellular phone No.

"applied."(1)番 号回数日

5MonthPlease write the complete
address for "Home town/city."
And for Chinese students,
please writein Chinese
6 配偶者の有無

FranceHome town/city

電話番号Passport

月2YearMarital status

8 本国における居住地

Address in Japan

10 旅券

年

1996

FrancePlace of birthStudent

9 日本における連絡先

40mm×30mm

Date of birth

Please write the name of thecountry, province, and city
underGiven
thename"Place of birth."

KEIO HANAKO

Name

Photo

2 生年月日FrenchNationality/Region

写 真回time(s)直近の出入国歴年

2015

The latest entry from9Year

月日

8MonthDayからto2015

年

Year9月Month21日

Day18 過去の在留資格認定証明書交付申請歴
Be sure to circle "Yes" or "No." 有 ・ 無
Yes

Past history of applying for a certificate of eligibility（上記で『有』を選択した場合）(Fill in the followings when the answer is "Yes")

/No

回数回
time(s)19 犯罪を理由とする処分を受けたことの有無 （日本国外におけるものを含む。）※交通違反等による処分を含む。
Criminal record (in Japan / overseas)※Including dispositions due to traffic violations, etc.
Be sure to circle "Yes" or
有 （具体的内容
Yes ( Detail:20 退去強制又は出国命令による出国の有無
Be sure to circle "Yes" orDeparture by deportation /departure order（上記で『有』を選択した場合）(Fill in the followings when the answer is "Yes")

回数回（うち不交付となった回数）（Of these applications, the number of times of non-issuance）

time(s)）・ 無)/No有 ・ 無Yes/

No回time(s)年

直近の送還歴The latest departure by deportation

Year月

Month日Day

21 在日親族（父・母・配偶者・子・兄弟姉妹・祖父母・叔(伯)父・叔(伯)母など）及び同居者
Family in Japan (father, mother, spouse, children, siblings,grandparents, uncle, aunt or others) and cohabitants

有 （「有」の場合は，以下の欄に在日親族及び同居者を記入してください。） ・ 無

Yes (If yes, please fill in your family members in Japan and co-residents in the following columns)

続 柄Relationship

氏 名Name

生年月日
Date of birth

Leave here blank unless you have

Be sure to circle "Yes" or/

国 籍・地 域 同居予定の有無
Nationality/Region

Intended to residewith applicant or notNo

勤務先名称・通学先名称
Place of employment/school

有・無Yes / No有・無Yes / No有・無Yes / No有・無Yes / No※ 3について，有効な旅券を所持する場合は，旅券の身分事項ページのとおりに記載してください。
Regarding item 3, if you possess your valid passport, please fill in your name as shown in the passport.
21については，記載欄が不足する場合は別紙に記入して添付すること。なお,「研修」，「技能実習」に係る申請の場合は，「在日親族」のみ記載してください。
Regarding item 21, if there is not enough space in the given columns to write in all of your family in Japan, fill in and attach a separate sheet.
In addition, take note that you are only required to fill in your family members in Japan for applications pertaining to “Trainee” or “Technical Intern Training”.

（注） 裏面参照の上，申請に必要な書類を作成して下さい。
Note : Please fill in forms required for application. (See notes on reverse side.)（注） 申請書に事実に反する記載をしたことが判明した場合には，不利益な扱いを受けることがあります。
Note : In case of to be found that you have misrepresented the facts in an application, you will be unfavorably treated in the process.

在留カード番号
特別永住者証明書番号
Residence card number
Special Permanent Resident Certificate number

申請人等作成用 ２Ｐ （「留学」）

22 通学先(1)名 称

Place of study

慶應義塾大学

Name of school(2)所在地

For certificate of eligibility

SAMPLE(3)電話番号

東京都港区三田2－15－45

Address

在留資格認定証明書用

Please check yourmost recent/current
undergraduate or
postgraduate
degree program.

For applicant, part 2 P ("Student")

03-5427-1778

Telephone No.

23 修学年数 （小学校～最終学歴）

年
14Years
Please do not forget
Education (last school or institution) or present school
24 最終学歴 （又は在学中の学校）
to choose your(1)在籍状況
□ 卒業
■ 在学中
□ 休学中
□ 中退
registered
Registered enrollment
Graduated
In school
Temporary absenceenrollment
Withdrawal
status as
as your degree □ 専門学校
□ 大学院 （博士）□ 大学院 （修士）
■ 大学
□well
短期大学
Total period of education (from elementary school to last institution of education)

DoctorMaster□ 高等学校□ 中学校

Senior high school(2)学校名Name of the school

Bachelor□ 小学校

Junior high school

Elementary school

Junior college

College of technology□ その他 （）Others(3)卒業又は卒業見込み年月

University of XXXX

Date of graduation or expected graduation

年20XX

YearX

月
Month25 日本語能力 （専修学校又は各種学校において日本語教育以外の教育を受ける場合に記入）

Japanese language ability (Fill in the followings when the applicant plans to study at advanced vocational school or vocational school(except Japanese language))
Proof based on a Japanese language test
□ 試験による証明
Name of the test
Attained level or score（１）試験名（２）級又は点数

Do not fill in these sections
Organization and period to have received Japanese language education□ 日本語教育を受けた教育機関及び期間
機関名
Organization

期間：Period年月

YearfromMonthから年toYear

月

Monthまで□ その他

OthersWhat
you declare in No. 27 MUST correspond to a certificate of deposit balance from a bank and/or a statement offinancial support.
A total amount of section No. 27(1) MUST be at least JPY130,000. (The average cost of monthly living expense in Japan is
JPY130,000 if youlive in a Keio housing.)
26 日本語学習歴（高等学校において教育を受ける場合に記入）
Japanese education history (Fill in the followings when the applicant plans to study in high school)

Choose the method of support and write an average amount of support per month.
日本語の教育又は日本語による教育を受けた教育機関及び期間

Organization and period to have received Japanese language education / received education by Japanese language*If
you check “Self” solely in (1), you must fill in YOUR information in (2).
機関名Organization

期間：Period年月

YearfromMonthからto年

Year

月Monthまで

27 滞在費の支弁方法等（生活費，学費及び家賃について記入すること。）※複数選択可
Method of support to pay for expenses while in Japan(fill in with regard to living expenses, tuition and rent) * multiple answers possible
Method of support and an amount of support per month (average)(1)支弁方法及び月平均支弁額□ 本人負担円

Self□ 在外経費支弁者負担

Yen□ 在日経費支弁者負担
Write the information about your financial
Supporterin Japansupporter(e.g.,father, mother) if you chose□ その他
either "Supporter living abroad" or 円
Others"Supporter in Japan" in No. 27(1).
Yen円

Supporter living abroad円

Yen

Yen

□ 奨学金

円

Scholarship

Yen

Write down both theoccupation(title) and the name of
the company where yoursupporter belong to.
(2)経費支弁者（複数人いる場合は全てについて記入すること。）※任意様式の別紙可youchecksolelyin (1),Supporter(If there is more than one, give information on all of the supporters )*another paper may be attached, which doesIfnot
haveto use “Self”
a prescribedformat.
writedown“Unemployed①氏 名
Keio Taro(student)”.
Name
②住 所
Address1234 Paris, Cedex 5678 France③職業 （勤務先の名称）
Occupation (place of employment)④年 収
Annual income

電話番号

XXXX Inc.
XXXX

電話番号Telephone No.
Telephone No.

円
Yen

Fill in the amount in JAPANESE YEN.
If you check “Self” solely in (1), fillin the current balance of your bank+33-1-1234-XXXX+33-1-1234-XXXX

Make sure to fill in
Business telephone
No. if applicable.

申請人等作成用 ３Ｐ （「留学」）

在留資格認定証明書用

SAMPLEFor applicant, part 3 P ("Student")

For certificate of eligibility(3)申請人との関係 （上記(1)で在外経費支弁者負担又は在日経費支弁者負担を選択した場合に記入）
Relationship with the applicant (Check one of the followings when your answer to the question 27(1) is supporter living abroad or Japan)

□ 夫

□ 妻

Husband■ 父Wife□ 母Father□ 兄弟姉妹□ 祖父

Mother□ 叔父 （伯父）・叔母（伯母）Brother / Sister□ 養父Grandmother

Foster father□ 受入教育機関

Uncle / Aunt

□ 友人・知人の親族□ 祖母Grandfather□ 養母
Foster mother□ 友人・知人

Educational institution

Friend / Acquaintance□ 取引関係者・現地企業等職員

Relative of friend / acquaintanceBusiness connection / Personnel of local enterprise□ 取引関係者・現地企業等職員の親族□ その他 （Relative of business connection / personnel of local enterprise）

Others(4)奨学金支給機関 （上記(1)で奨学金を選択した場合に記入）※複数選択可
Organization which provide scholarship (Check one of the following when the answer to the question 27(1) is scholarship) * multiple answers possible□ 外国政府Foreign government□ 地方公共団体□ 日本国政府
Japanese government

Local government□ 公益社団法人又は公益財団法人 （28）

Public interest incorporated association /Public interest incorporated foundation
Plans after graduation
卒業後の予定■ 帰 国□ その他 （）Others□ 日本での進学

Return to home countryEnter school of higher education in Japan□ 日本での就職□ その他 （Find work in JapanOthers）

29 本邦における申請人の監護人（通学先が中学校又は小学校の場合に記入）
Actual guardian in Japan ( Fill in the following if the applicant is to study at a junior high school or elementary school )(1)氏 名(2)本人との関係

Name

Relationship with the applicant(3)住 所
Address

電話番号
Telephone No.

This is for Keio to fill in, so
please leave this section blank.

携帯電話番号
Cellular Phone No.

30 申請人，法定代理人，法第７条の２第２項に規定する代理人
Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.

(1)氏 名(2)本人との関係

Name(3)住 所

東京都港区三田2-15-45 慶応義塾大学学生部学事グループ法務研究科担当

Address

電話番号Telephone No.

携帯電話番号03-5427-1778

N/A

Cellular Phone No.

以上の記載内容は事実と相違ありません。
申請人（代理人）の署名／申請書作成年月日

注 意

受入機関職員Relationship with the applicant

I hereby declare that the statement given above is true and correct.
Signature of the applicant (representative) / Date of filling in this form

年月日

YearMonthDay

Do not fill in these sections

申請書作成後申請までに記載内容に変更が生じた場合，申請人（代理人）が変更箇所を訂正し，署名すること。
申請書作成年月日は申請人（代理人）が自署すること。

Attention

In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant (representative) must correct thepart concerned and sign their name.
The date of preparation of the application form must be written by the applicant (representative).

Agent or other authorized person※ 取次者(1)氏 名Name(3)所属機関等(2)住 所

Address
Organization to which the agent belongs

電話番号

Telephone No.