Request Form for Pursuing Dual Employment as an Executive

SupplementaryForm No. 2(Executive of Company Developing Applications of Research)○○/○○/20○○

President of Tohoku University
I would like to ask for your consent to the request of the employee below to pursue dual
employment.
Corporate Name:□□□□ Co., Ltd
Stamp
Representatives name:Ichiro ○○StampDocument Number:

Website address: http://www.tohoku.ac.jp/japanese/index.html
Content of Business

Address of work location (starting with the post code):
Frequency of Work: □ Every___day____:____ - ____:____■
6times per year / month / week / other period■ Other ()1 time = 5 hours

Developing applications of research results and related business (Development, manufacture and sale of ○○○equipment, Development, manufacture and sale of □□ equipment, protection of intellectual property, transportand sales, technology consulting in the area of □□□, and other related business activities.

Parent Company:■ No□ Yes

Name of Company:
Location
Outline of the Contents of the Company's Business

Name of employee requesting dual employment: Saburo ○○Affiliation: Graduate School of Economics and Management
Position Title: Director
Content of responsibilities:
Right to represent the company
Administrative Responsibilities
Content of responsibilities■ No□ NoJob title: Professor

□ Yes
■ Yes

Participating in the making of important decisions related to the conduct of the company's business, and theconduct of administrative work, mainly in relation to applications and commercialization of the research results
in relation to △△△△. There is no involvement at all in the negotiation and conclusion of contracts between
this company and the University.

Address of the company where the applicant will be dually employed(starting with the post code): 1-1-1 △△, ○○-ku, ○○-shi, ○○prefecture ○○○―○○○○
Affiliated department, supervisor, contact telephone number: ○○Section
Jiro △△○○○―○○○○

Period of Dual Employment：□ From Date of Permission
for Dual Employment
To: ○○/○○/20○○■ ○○/○○/20○○■ Yes
5 million yen(year(s) / month(s) / day(s) /Other (Transportation Costs: □ No
■ Yes

Remuneration1: □ No
per1time(s)/hour(s)))

Number of special shares of stock possessed by the applicant for dual employment / total numberof shares of stock already granted by the company in question
100
shares /1000
shares
Details of any contractual relationships2involving the employing company within a two year
period prior to the anticipated start date of dual employment with the employing company andTohoku University
■ No
□ Yes
* Details are attached on a separate sheet

Contents of any government support etc for development of commercial application of the said research results by the company in question (Only enter in the case of dual employment as an officer ofthe company applying the research results.)□ No■ Yes
* Concrete details are attached on a separate sheet

1This includes not only realized capital gains such as money and marketable securities, but also gains in the form of stock options and financial guarantees by the company inquestion.
2 Include whether or not the applicant participated in planning that led to the decision to approve the contract, and all other relevant details regardless of whether the applicant
held decision making authority in that regard or not. Also include any involvement in joint research and commissioned research. Include results even if they did not give riseto any contractual effect, provided a contract was concluded within the period of the past two years.

(Attachments)
Details of any contractual relationships involving the employing company within a two year period prior to the anticipated start date of dual employment with the employing company
and Tohoku University
Fiscal/AcademicContract Details
Amount of the Contract
Year

FY 20___FY 20___FY 20___

Anticipated

Total
Contents of any government support etc for development of commercial application of the said research results by the company in question (Only enter in the case of dual employment as anofficer of the company applying the research results.)
Financial support for the commercialization of this departments research results has been received from the Japan Science and Technology Agency. Support from the development of new
business in expanding on the research and development results was obtained from a venture capital firm, who green-lighted the proposal for research and development of “△△△△”
and funded it for a three year period from ○○/○○ for an amount of ______ million yen.
* This form may be changed to incorporate additional details as necessary.
I guarantee that all of the above information is true and correct.
＿＿ /＿＿/20＿＿

Corporate Name:
Representative’s name:

Seal
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