Dual Employment Request (Part-Time Medical Practitioner ／ Part-Time Lecturers)
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 case of intensive courses etc.,
where this has not yet been decided,
enter the number of classes and overall
hours etc. in as much detail as possible.
* 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 dualemployment.
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* It is not necessary to enter details of the Content of Business
Name of employee requesting dual employment: Ichiro Aoba Job title: Professor
Affiliation: Graduate School of ○○○ Research Department
Position Title: Commissioned Doctor (Part Time Doctor)
Content of responsibilities: Providing medical examination and treatment to inpatients andoutpatients (as a physician).
(Delivering lectures on ○○ theory to undergraduates)* In all cases enter who the application refers to, and, in the case of a part-time employed medical
practitioner, the "area of practice", in the case of an instructor employed part-time, the "subject
area of the classes", or, in the case of a research lecturer, the "lecture theme".

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
13:00 - 17:00□times per year / month / week / other period□ Other ()1 time =4hours

Anticipated
Period of Dual
Employment

From August 1, 2010 to March 31, 2011

It is not possible toobtain permissionretroactively.

Remuneration: □ No ■ Yes
20,000yenper
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 anobligation 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".