Dual Employment Request (Others)
Please write within the bold lines.

* In the case where your organization
does not have a home page, thisdoes not have to be entered.

* Please enter this if it is different to the location of the company
providing the secondary employment.

* Please enter concrete details.
In the event of any irregularities,
please enter the details in the section
marked "Other".
* Enter your organization's file reference number.

Attachment 1
Dual Employment Request (Application for Permission for Dual Employment / Permission Form)
President of Tohoku University
Document Number: ○○○○ No. ××××
April 1, 2010
I would like to ask for your consent to the request of the employee below to pursue dual
employment.
Address of the company where the applicant will be dually employed (starting with the post code):
Organization Name:○－○－○ ○○cho, Minato-ku, Tokyo ○○○－○○○○
Representative:
Website address: http://www.tohoku.ac.jp/japanese/index.html
Content of Business: Contributing to academic research in Japan by assisting academic research,
supplying funds for the development of researchers, carrying out research related to applications ofacademic research.
* Enter items related to the "objective" of agreements and contributions. In the case of national orregional public organizations enter the relevant portion of the regulations etc. of the committee inquestion. It is not necessary to enter anything in this section in the case of a National Committee ofInquiry
Name of employee requesting dual employment: Ichiro Aoba Job title: Professor
Affiliation: Graduate School of ○○○ Research Department
Position Title: ○○○○Specialist Committee Member
Content of responsibilities: Providing medical examination and treatment to inpatients andoutpatients (as a physician).
Carrying out investigations relating to the distribution, promotion and evaluation of ○○○ assistancepayments from the position of someone with a record of scholarship, as a specialist member of the○○○○ committee.

* Please enter concrete details of the content of any duties. No employment may
be engaged in other than as recorded in this section. In the case of involvement
in clinical trials, make sure to enter the essential details here.

Affiliated department, supervisor, contact telephone number:
General Affairs Department, General Affairs Section
Address of work location (starting with the post code): ○－○ ○○cho, Chiyoda-ku, Tokyo ○○○－○○○○
Frequency ofWork:□ Every Week Friday ____:____ - ____:____■ 6 times per year / month / week / other period□ Other ()1 time =2hours

Anticipated
Period of Dual
Employment

From August 1, 2010 to March 31, 2011

It is not possible toobtain permission
retroactively.

Remuneration: □ No ■ Yes
10,000yenper
1 (year(s) / month(s) / day(s) / time(s) / hour(s))
Other (Travel Expenses: □ No ■ Yes)In the case where there has been a request for disclosure of the relevant request for dual employment, check that there are obstacles to disclosure.：□ Organization Name (Including Name of Representative / Contents of Business) ■ Title of Office ■ Content of Duties* In the case where disclosure of corporate documents is requested under Article 3 of the [Law Regarding Access to Information Held by Independent Administrative Agencies], the University has an
obligation to disclose that information under Article 5 of the same legislation. However, under ordinary circumstances, it is not the case that everything in the requested documents must be disclosed. Only
the portion(s) of a document containing information listed in the sections of Article 5 need be disclosed. This disclosure must be partial disclosure as set out in Article 6 of the same legislation. The
remainder of the document is exempt from disclosure. In future, in the event of a request for disclosure of corporate documents relating to the dual employment that is the subject of this request, make sure
to check that there are no obstacles to disclosure under Article 5 of the "Law Regarding Access to Information Held by Independent Administrative Agencies".