PRIVACY ACT STATEMENT※Using correction tapes/white-outs is allowed for items other than "Signature ofAUTHORITY : 5 US Code Section 552a(e)(3)
PRINCIPAL PURPOSE(S) : To maintain personal history statement from employees.
ROUTINE USE(S) : Used by both USFJ installations and the Government of Japan in collecting personal history statement.
The information provided may be disclosed to any DoD component in the pursuit of their official duties.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION:As stated here, please use the separate paper (A4 size) when you
The information solicited in this form is mandatory for officials of both USFJ installations and the Government of Japan collecting personal history statement.
morethisspacesto fill inmay
information.
Please annotate
the block
Failure needto furnish
information
impede processing
the employment
action in accordance with Master Labor Contract , Marines Contract , and Indirect Hire
number(s) when using a separate paper. You can also attach a copy
Agreement.

of the blankPERSONALUSFJ Form 196aEJ.
PleaseSTATEMENT
make sure to put all papers
HISTORY
together with a staple on the履 left
歴 top.
書PART A - GENERAL INFORMATION
IF MORE SPACE IS REQUIRED, USE SEPARATE SHEETS OF PAPER
IDENTIFYING EACH ITEM BY NUMBER.

記入欄が不足の時は別紙に項目番号をつけて記入して下さい
2. 生年月日

1. 氏名（フリガナ）

2. DATE OF BIRTH

1. NAME (Last，First)

Tokyo, Taro
3. 現住所（〒-）

12 Dec 1970

3. PRESENT ADDRESS （〒 １１１-００００ ）Please use the Western
１－１－１ ○○-cｈｏ, Ｍｉｎａｔｏ－kｕ,
Calender forTokyo
dates throughout

Enter the phone number that you
4.電話番号（自宅又は携帯）

this Form.

5.電話番号（職場）

6.性別

4.HOME OR CELLULAR PHONE NO. 5.WORK PHONE NO.

03-111-1111

6.SEX

03-999-9999

M

Fill this block if you do notlmo-031@gmail.com have a Japanese citizenship

7.Eメールアドレス

7.E-MAIL ADDRESS

8. 健康状態および身体障害の種類、等級、傷痕などの特徴

8. PHYSICAL CONDITIONS，KIND & DEGREE OF HANDICAPS, SCARS, ETC.

9. 国籍

9. CITIZENSHIP(YES)"
10. RESIDENCE CARD NO.AND PERIOD "GRADUATEDVALIDITY

Japanese

includes completion
N/A

Excellent
在留カード番号および有効期限年月日
Write ALL10.citizenships
if you have multiple
citizenships.
11. 米国軍人/軍属の配偶者又は扶養家族ですか？
If you do NOT have a Japanese citizenship,
いいえはいattach a copy of your valid Residence
Card or いいえ
SpecialPermanentResident
Certificate,12.
学 歴 （古い順に記載）
年 月
Passport, and Permanent Resident Visa.
学校

11. ARE YOU A SPOUSE OR DEPENDENT FAMILY MEMBER OF U.S. MILITARY/CIVILIAN？

YES
卒業
12.
卒業
中退

×

EDUCATION （IN CHRONOLOGICAL ORDER）

NO

YEAR-MONTHGRADUATEDYESNOSCHOOL

Minato Elementary School, Minato Ward, Tokyo
学科

よりCOURSE

FROM

ADDRESSTO

Start from Elementary School所在地までApr 1977
1-1 ○○-cho Minato-ku, Tokyo学校
学科

×Mar 1983

SCHOOL

Check "YES" for other than transfer, drop out, currently Minato Junior High School, Minato Ward, Tokyo
COURSE
FROMenrolled, or currently absentより

Apr 1983

所在地
学校
学科
所在地

まで

ADDRESSEnter "Study Abroad" after the name of
2-2 ○○-cho Minato-ku, Tokyo
school if you attended as an international SCHOOL
student
Minato High School, Minato Ward, Tokyo
より

Include "City", "State", and "Country" ifoutside Japan
まで

COURSEMar 1986

FROMGeneral
ADDRESS

Apr 1986
×TO

3-3 ○○-cho Minato-ku, Tokyo学校

×

TOMar 1989SCHOOLLMO High School （Study Abroad）
学科
所在地

If you are currently enrolled or absent, no より
need to check "YES" or "NO" but fill in thecurrent status
まで

COURSEADDRESS

SFO, CA, USA学校

FROMGeneral

Apr 1988
×TOMar 1989SCHOOL

When you are downloading this Form from internet or already have the Minato Institute of Technology (Private School)
学科 Form in an electronic format, please ensure to use
より the most current version.
COURSEFROM
Apr 1989
The most current version has the date of "20210324" at the left bottom of BS in Information Technology
所在地
まで
ADDRESSTO
the Form
4-4 ○○-cho Minato-ku, Tokyo

USFJ FORM 196aEJ, 20210324 (EF)PREVIOUS EDITIONS ARE OBSOLETE.

×Mar 1993
PAGE 1 OF 2 PAGES

13. 免許証、証明書、その他の技能、資格

13. LICENSES， CERTIFICATES, AND JOB-RELATED SKILLS・ Ordinary Driver's License, 19XX
･ Certificate of Software Development Engineering, 20XX
･ ○○ License, 20XX･ TOEIC（８７０）, 20XX
I am able to lift up 10kg objects.

Annotate your score of language proficiency test such as
TOEIC, if any. Attach a copy of certificate of all yourcertificates and licenses to this form.
英文タイプ語/分
14. 職歴（失業期間も含めて新しいものから記載）
年If you apply for a position that requires physical ability,
雇用主又は会社名

月SAN-A ●●Store （Dispatch）

for example, to lift up 10kg object, write that you meetより
the requirement.

住所

ADDRESS

1-1 ○○-cho Shinagawa-ku, Tokyo

まで
職種

ENGLISH TYPING
WPM
14. LIST ALL EMPLOYMENT (STARTING FROM MOST RECENT, INCLUDING
YEAR-MONTHPERIODS OF UNEMPLOYMENT)EMPLOYER

Please fill in information for each position even the employer/companyPOSITION
is the same

REASON FOR LEAVING

雇用主又は会社名

EMPLOYER
よりSpecify reasons for leaving.

1-1 ○○-cho Shinjuku-ku, Tokyo

職種

POSITION

退職理由REASON FOR LEAVING

雇用主又は会社名

EMPLOYER

住所

職種Nov 2016

TOMar 2017

FROMOct 1998

TOOct 2016Low wage

Unemployed

1-1 ○○-cho Shinjuku-ku, Tokyo

まで

FROM

Clerk

ADDRESSより

PresentSAN-A ●●Store （Dispatch）

ADDRESSまで

Apr 2017

TO

Sales Clerk

退職理由

住所

FROM

POSITION

Write your unemployed period, if any.

退職理由

REASON FOR LEAVING

雇用主又は会社名

EMPLOYER

住所

LMOＢank Inc. ●●Branch

ADDRESS

より

1-1 ○○-cho Shibuya-ku, Tokyo

まで
職種

POSITION

退職理由

REASON FOR LEAVING

雇用主又は会社名

EMPLOYER

Write "None," if you have no record of law
より
violations.

住所Apr 1996

TOSep 1998

Clerk
Voluntary resignation due to reduction of the operation
department
LMOＢank Inc. ●●Branch

ADDRESS

1-1 ○○-cho Suginami-ku, Tokyo

までFROMFROMApr 1993

TOMar 1996

職種POSITION

退職理由

REASON FOR LEAVING

15. 法律違反のために逮捕、起訴、又は有罪の判決をこれまでに受けたことがあればその詳細を記入する（交通違反及び事故を含む）。法律違反がない場合は「ない」と記入する。

15. . ENTER COMPLETE CIRCUMSTANCE IF YOU HAVE BEEN ARRESTED,INDICTED,ORCONVINCED FOR ANY VIOLATION OF LAW (INCLUDING TRAFFIC VIOLATION AND ACCIDENTS).
IF NONE,SO STATE.

Wet-Ink Signature of Applicant.
You may sign your name in Japanese or in English.
This form will NOT be accepted without your signature.
16.
入職可能日 signature and seal(han) will also NOT beCorrectedaccepted.
17. 応募するにあたり、どのようにして情報を得ましたか？
（） ハローワーク（（） 基地従業員の紹介（氏名・部隊・電話番号）

Constant overtime

None

16. AVAILABLE DATE

1７. SOURCE OF JOB INFORMATION, IF APPLICABLE） 米軍空席広報（（Interpreter） エルモホームページ） その他（詳細記述）（） HELLO WORK（） USFJ VACANCY（） USFJ EMPLOYEE(NAME,ACTIVITY,PHO)（ × ） LMO HOMEPAGE

18. この履歴書中の全ての項目について、もし虚偽の記述をした場合には直ちに解雇又は就職申込が不承認になりうることを私は承知しています。
ここに記入した事柄は私の知る限り、また信じる限り事実であることの証明として署名します。
I UNDERSTAND THAT FALSIFICATION OF ANY ITEM HEREIN MAY RESULT IN THE IMMEDIATE TERMINATION OF MY EMPLOYMENT OR DISAPPROVAL OF MYAPPLICATION. I PLACE MY SIGNATURE IN CERTIFICATION THAT THE INFORMATION CONTAINED HEREIN IS THE TRUTH TO THE BEST OF MY KNOWLEDGE AND BELIEF.
DATE 年月日SIGNATURE OF APPLICANT 求職者の署名

USFJ FORM 196aEJ, 20210324 (REVERSE)PREVIOUS EDITIONS ARE OBSOLETE.

PAGE 2 OF 2 PAGES