Example of Application Form to the Immigration Office
別記第二十八号様式（第十九条関係）

日本国政府法務省
Ministry of Justice, Government of Japan

Students residing
outside the Kinki
region must
address the form
to the appropriate
local immigration
office.

資格

外活動許可申請書

APPLICATION FOR PERMISSION TO ENGAGE IN ACTIVITY OTHER THAN THATPERMITTED UNDER THE STATUS OF RESIDENCE PREVIOUSLY GRANTED
To the Director General ofOsaka 入国管理局長

殿Regional Immigration Bureau

出入国管理及び難民認定法第１９条第２項の規定に基づき，次のとおり資格外活動の許可を申請します。
Pursuant to the provisions of Paragraph 2 of Article 19-2 of the Immigration Control and Refugee Recognition Act, I hereby apply for permission toengage in activities other than those permitted under the status of residence previously granted.

1 国 籍・地 域
If different fromResidence Card,
have the card
amended atward office/cityhall.

２ 生年月日FrenchNationality / Region

3 氏 名
Name

4 性 別
Sex

XXXX

Date of birth

年

XX 月YearMonthXX 日Day

Lefevre Jean
男 ・ 女
○

○

5 配偶者の有無

7 住居地

College Student

Occupation

123-45, XXXXXX, XXXXXXX, XXXXXXXX

Address in Japan

電話番号

携帯電話番号

Telephone No.

XXX-XXX-XXXX

Cellular Phone No.

8 旅券 (1)番 号
Passport

6 職 業

有 ・ 無

Married / Single

Marital status

Male/Female(2)有効期限XXXXXXXX

Number9 現に有する在留資格

月XX Month

在留期間College Student

Status of residence

年
XXXX Year

Date of expiration

日XX Day

X yrs.

Period of stay

在留期間の満了日 XXXX 年
月日
10 在留カード番号
XX Month
XX DayYear
Residence card No.
11 現在の在留活動の内容（学生にあっては学校名及び週間授業時間）

XXXXXXXX

Date of expiration

Present activity (for student: name of school, lesson hours per week)

The current
permitted "periodof stay" (tenpossible types: 3momths, 6 months,
1 year, 1year and 3months, 2 years, 2years and 3months,
3 years, 3 years
and 3 months, 4years, or 4 years
and 3 months).
Note: NOT the total
length of time you
have been/will bein Japan.

Kyoto University, XX hours per week
Other activity to engage in
12 他に従事しようとする活動の内容(1)職務の内容□ 翻訳・通訳□ 語学教師Type of activity

Translation / Interpretation(2)雇用契約期間(4)報酬

SalaryX,XXXMonthly□ 週額

WeeklyUp to and notexceeding 28
hours per week.

XX hrs.

Working hours per week

円 （ □ 月額YenOthers(3)週間稼働時間

X daysTerm of employment contract■ その他（ シンポジウムの手伝い ）Language teaching■ 日額 ）
Daily

13 勤務先 Place of employment(1)名称
Graduate school of XXX, Kyoto UniversityName(2)所在地
Address(3)業種

Type of businessYoshida-honmachi, Sakyo, Kyoto 606-8501□ 製造Manufacturing□ 商業

Name075-XXX-XXXX□ 教育

Commerce

14 法定代理人（法定代理人による申請の場合に記入）(1)氏 名

電話番号

Telephone. No.

□ その他

Education

OthersLegal representative (in case of legal representative)(2)本人との関係
Please leave thisarea blank.
Relationship with the applicant(3)住 所Address

電話番号

携帯電話番号

Telephone No.

Cellular Phone No.
以 上 の 記 載 内 容 は 事 実 と 相 違 あ り ま せ ん 。 I hereby declare that the statement given above is true and correct.

申請人（法定代理人）の署名／申請書作成年月日

Signature ofapplicant

Jean Lefevre

Signature of the applicant (legal representative) / Date of filling in this form

XXXX

年Year月XX MonthXX日Day

注 意 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（法定代理人）が変更箇所を訂正し，署名すること。
Attention In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant (legal※representative) must correct the part concerned and sign their name.
取次者 Agent or other authorized person(1)氏 名Name(3)所属機関等(2)住 所this area blank.
Please leave
Address

Organization to which the agent belongs

電話番号

Telephone No.