ᅾ␃㈨᱁ㄆᐃド᫂᭩஺௜⏦ㄳ᭩ࠉグධ᫬ࡢὀព஦㡯࣭⿵㊊
Notes and Supplementary Information for Completing a Application form for a certificate of eligibility
࣭Excelࣇ࢓࢖ࣝ࡟ᡭධຊࡋ࡚ࡃࡔࡉ࠸ࠋᡭ᭩ࡁࡢ⏦ㄳ᭩ࡣཷࡅ௜ࡅࡲࡏࢇࠋ
ࠉPlease enter the information manually in an Excel file. Handwritten applications will not be accepted.
࣭㯤Ⰽࡢ㡯┠ࡣ඲ဨධຊᚲ㡲࡛ࡍࠋ㯤Ⰽࡢ⟠ᡤࡣᚲࡎධຊࢆࡋ࡚ࡃࡔࡉ࠸ࠋ㸦ධຊࡍࡿ࡜Ⰽࡣᾘ࠼ࡲࡍ㸧
ࠉAll yellow fields must be filled in. Yellow fields must be completed.(Yellow colour disappears whenentered).
෗┿㸸᭱㏆3ࣨ᭶௨ෆ࡟᧜ᙳࡋࡓୖ༙㌟ṇ㠃⬺ᖗࡢࡶࡢࠋ෗┿ࢹ࣮ࢱࢆ㈞ࡾ௜ࡅ࡚ࡃࡔࡉ࠸ࠋ
Photo:Upper body, frontal view, hatless, taken within the last three months. Please paste the photo data.

Please leave question #7 and #9

Please leave question #11

3.Ặྡ㸸ࣃࢫ࣏࣮ࢺ࡟グ㍕ࡉࢀ࡚࠸ࡿ࢔ࣝࣇ࢓࣋ࢵࢺ⾲グ࡛グධࡍࡿࡇ࡜㸦₎Ꮠ୙ྍ㸧
3.name㸸Please fill in using the alphabet notation as written in your passport (no kanji).
ࠕ4.ᛶูࠖࠕ6.㓄അ⪅ࡢ᭷↓ࠖࠕ15.ྠక⪅ࡢ᭷↓ࠖࠕ17.㐣ཤࡢฟධᅜṔࠖࠕ20㏥ཤᙉไཪࡣฟᅜ࿨௧࡟ࡼࡿ
ฟᅜࡢ᭷↓ࠖࠕ21ᅾ᪥ぶ᪘ཬࡧྠᒃ⪅ࠖࡢ㡯┠ࡣ㯤Ⰽ࡟࡞ࡗ࡚࠸ࡲࡏࢇࡀࠊ඲ဨධຊᚲ㡲㡯┠࡛ࡍࠋヱᙜࡍࡿ᪉࡟ࠐࢆධࢀ࡚ࡃࡔࡉ࠸ࠋ
[4. Sex][6. Marital Status][ 15. Accompanying Persons][17. Past Entry into/Depature from Japan] [ 20.
Departure by Deportation /Departure order] [21. Family in Japan and cohabitants] are not highlighted inyellow but are mandatory fields. Please circle㸦ࠐ㸧 the appropriate option.
5.ฟ⏕ᆅ㸸ฟ⏕ᆅࡢఫᡤࢆᅜྡࠊᕞ㸦┬㸧ཬࡧ㒔ᕷྡࡲ࡛グධࡋ࡚ࡃࡔࡉ࠸ࠋ㸦୰ᅜ⡠ࡢ᪉ࡣ₎Ꮠ࡛グධࡋ࡚ࡃࡔࡉ࠸㸧
5.Place of birth:Please write your place of birth address, including the country name, state (province),and city name.
8.ᮏᅜ࡟࠾ࡅࡿᒃఫᆅ㸸ẕᅜࡢఫᡤࢆᅜྡࠊᕞ㸦┬㸧ཬࡧ㒔ᕷྡࡲ࡛グධࡋ࡚ࡃࡔࡉ࠸ࠋ
8.Home Town/city:Please write your home country's address, including the country name, state(province), and city name.
7࣭9࣭11:グධ୙せ㸦ධຊࢆኚ᭦ࡋ࡞࠸࡛ࡃࡔࡉ࠸㸧7࣭9࣭11.:Not required (do not change entries)
14.⁫ᅾணᐃᮇ㛫㸸࠶࡞ࡓࡢ␃Ꮫᮇ㛫㸦༙ᖺor1ᖺ㸧ࢆධຊࡋ࡚ࡃࡔࡉ࠸ࠋ
14. Intended length of stay:Please input the duration of your study abroad (6 months or 1 year).
16.ᰝド⏦ㄳணᐃᆅ㸸⏦ㄳணᐃᆅࢆධຊࡋ࡚ࡃࡔࡉ࠸ࠋ⏦ㄳᆅࡣ௨ୗURLࢆཧ⪃࡟ࡋ࡚ࡃࡔࡉ࠸ࠋ
16. Intended Place to Apply for Visa: Please enter the intended place of application.Please refer to thefollowing for application locations.
https://www.mofa.go.jp/about/emb_cons/over/index.html
17.㐣ཤࡢฟධᅜṔ㸸┤㏆ࡢฟධᅜṔࡣࠊࣃࢫ࣏࣮ࢺࡢࢫࢱࣥࣉ࡞࡝࡛☜ㄆࡋࠊ᪥௜ࢆṇ☜࡟グධࡋ࡚ࡃࡔࡉ
࠸ࠋ
17.Past Entry into/Depature from Japan: The most recent entry and departure history should be verified
by passport stamps or other means and dated accurately.

Please leave question #22

ᅾ␃㈨᱁ㄆᐃド᫂᭩஺௜⏦ㄳ᭩ࠉグධ᫬ࡢὀព஦㡯࣭⿵㊊
Notes and Supplementary Information for Completing a Application form for a certificate
of eligibility࣭㯤Ⰽࡢ㡯┠ࡣ඲ဨධຊᚲ㡲࡛ࡍࠋ㯤Ⰽࡢ⟠ᡤࡣᚲࡎධຊࢆࡋ࡚ࡃࡔࡉ࠸ࠋ㸦ධຊࡍࡿ࡜Ⰽࡣ
ᾘ࠼ࡲࡍ㸧ࠉAll yellow fields must be filled in. Yellow fields must be completed.(Yellow colour
disappears when entered).
22࣭26࣭27:グධ୙せ㸦ධຊࢆኚ᭦ࡋ࡞࠸࡛ࡃࡔࡉ࠸㸧
22࣭26࣭27:Place of Study:Not required (do not change entries)

23.ಟᏛᖺᩘ㸸ᑠᏛᰯ㹼⌧ᅾ㸦኱Ꮫ࡛ࡢᅾ⡠ᖺᩘྵࡴ㸧ࡲ࡛ࡢಟᏛᖺᩘࢆグධࡋ࡚ࡃࡔࡉ࠸ࠋ
23.Total Period of education㸸Please enter the total period of education from elementary
school to the present (including years at university).

Please leave question #26 and #27 blank!

28.⁫ᅾ㈝ࡢᨭᘚ᪉ἲ➼㸸
㸦1㸧ᨭᘚ᪉ἲཬࡧ᭶ᖹᆒᨭᘚ㢠㸸⤒㈝ᨭᘚ⪅ࢆ㑅ᢥ㸦ԏ㸧ࡋࠊ⏕ά㈝㸦ᐙ㈤ࢆྵࡴ㸧ࡢ᭶㢠ࢆグධࡋ࡚ࡃࡔࡉ࠸ࠋ
㸦2㸧⤒㈝ᨭᘚ⪅㸸⤒㈝ᨭᘚ⪅ࡀᮏே௨እ࡛࠸ࡿሙྜࡣࠊグධࡋ࡚ࡃࡔࡉ࠸ࠋ⤒㈝ᨭᘚ㔠㢠ࡀᮏேࡲࡓࡣዡᏛ㔠ࡢሙྜࡣࠊධຊ୙せ࡛ࡍࠋ⤒㈝ᨭᘚ⪅ࡢఫᡤࡣ┬␎ࡏࡎ࡟ṇ☜࡟グධࡋ࡚ࡃࡔࡉ࠸ࠋ⫋ᴗࡣࠊ໅ົඛࡢྡ⛠࡜ᴗ✀ࡀศ࠿ࡿࡼ࠺࡟グ㍕ࡋ࡚ࡃࡔࡉ࠸ࠋ
౛㸸ʹʹʹCo.Ltd㸦ᘓタᴗ㸧㸦3㸧ዡᏛ㔠㸸ዡᏛ㔠ࢆグ㍕ࡍࡿሙྜࡣࠊ᭶㢠ࡢ᪥ᮏ෇࡛グධࡋ࡚ࡃࡔࡉ࠸ࠋࡲࡓࠊ㱟㇂኱ᏛධᏛ㢪᭩㸦APPLICATION FOR ADMISSION ࡛ධຊࡋࡓ㔠㢠࡜ᕪ␗ࡀ↓࠸ࡼ࠺ὀពࡋ࡚ࡃࡔ
ࡉ࠸ࠋ
28. Method of support to pay for expenses while in Japan(1) Method of support and an amaount of support per month : Select (ԏ) the financial
supporter and indicate the monthly amount for living expenses (including rent).
(2) Supporter: If the financial supporter is someone other than the applicant, pleaseprovide their information. If the financial support comes from the applicant themselves ora scholarship, this section is not required. Include the complete and accurate address ofthe financial supporter. Provide the occupation, specifying the name of the employer andtheir industry.
Example: XYZ Co. Ltd (Construction Industry)(3) Scholarship: In the case you enter a scholarship, please enter the MONTHLY amountin JAPANESE YEN. Also, please make sure that you have entered the same monthly
amount in the online document [㱟㇂኱ᏛධᏛ㢪᭩㸦$33/,&$7,21)25$'0,66,21 @ᅾ␃㈨᱁ㄆᐃド᫂᭩஺௜⏦ㄳ᭩ࠉグධ᫬ࡢὀព஦㡯࣭⿵㊊
Notes and Supplementary Information for Completing a Application form for a certificate ofeligibility

28㸦4㸧⏦ㄳே࡜ࡢ㛵ಀ㸸28㸦2㸧࡛グධࡋࡓ⤒㈝ᨭᘚ⪅࡜ࡢ㛵ಀࢆ㑅ᢥ㸦ԏ㸧ࡋ࡚ࡃࡔࡉ࠸ࠋ
ࠉ㸦5㸧ዡᏛ㔠ᨭ⤥ᶵ㛵㸸28㸦1㸧࡛ዡᏛ㔠ࢆ㑅ᢥࡋࡓሙྜࠊ㐺ษ࡞ᶵ㛵ࢆ㑅ᢥ㸦ԏ㸧ࡋ࡚ࡃࡔࡉ
࠸ࠋ
28 (4) Relationship with the Applicant: Select (ԏ) the relationship with the financial
supporter entered in 28 (2).
(5) Organitation which provide scholarship: If you selected a scholarship in 28 (1), pleasechoose the appropriate institution (ԏ).

Please leave question #29

Please leave question #30 blank!

Please leave question #31 and after

29࣭30࣭31:グධ୙せ㸦ධຊࢆኚ᭦ࡋ࡞࠸࡛ࡃࡔࡉ࠸㸧
29࣭30࣭31:Place of Study:Not required (do not change entries)

別記第六号の三様式（第六条の二関係）
申請人等作成用 １

日本国政府法務省
Ministry of Justice, Government of JapanFor applicant, part 1

在 留 資 格 認 定 証 明 書 交 付 申 請 書
APPLICATION FOR CERTIFICATE OF ELIGIBILITY

法

務

大

臣

殿

To the Minister of Justice

写 真
Photo

出入国管理及び難民認定法第７条の２の規定に基づき，次のとおり同法第７条第１項第２号に掲げる条件に適合している旨の証明書の交付を申請します。

40mm×30mm

Pursuant to the provisions of Article 7-2 of the Immigration Control and Refugee Recognition Act, I hereby apply forthe certificate showing eligibility for the conditions provided for in 7, Paragraph 1, Item 2 of the said Act.

1 国 籍・地 域

2 生年月日CANADA

Nationality/Region

3 氏 名

SHIRLEY

Name
Male

Sex

7 職 業

Occupation

・/女Single/

携帯電話番号

075-645-7898(1)番 号

Cellular phone No.

(2)有効期限AB11111111

Number"Professor""Instructor"□ Ｌ 「企業内転勤」"Intra-company Transferee"□ M 「経営・管理」□ Ｎ 「研究」"Business Manager”"Researcher""Technical Intern Training ( i )""Technical Intern Training ( ⅲ )"

2024

Year

14 滞在予定期間"Long Term Resident"□ 「高度専門職（1号ハ）」

3

月

日

25

Month

□ Ｕ 「その他」"Highly Skilled Professional(i)(c)"

13 上陸予定港

Day

OthersOSAKAPort of entry

15 同伴者の有無

SIX MONTHS

Intended length of stay

16 査証申請予定地□ Ｔ「定住者」"Highly Skilled Professional(i)(b)"年"Dependent""Designated Activities(Dependent of Gradutate from a university in Japan)""Designated Activities(Dependent of EPA)"□ 「高度専門職（1号ロ）」"Highly Skilled Professional(i)(a)"□ Ｒ 「家族滞在」□ Ｒ「特定活動（本邦大卒者家族）」"Spouse or Child of Permanent Resident"□ 「高度専門職（1号イ）」"Trainee"□ Y 「技能実習（3号）」□ Ｔ「永住者の配偶者等」"Spouse or Child of Japanese National"□ Ｑ 「研修」"Student""Entertainer"□ Ｒ「特定活動（EPA家族）」□ Ｔ 「日本人の配偶者等」

Date of entry"Designated Activities (Graduate from a university in Japan)""Technical Intern Training ( ⅱ )""Designated Activities (Dependent of Researcher or IT engineer of a designated org)"

12 入国予定年月日"Engineer / Specialist in Humanities / International Services"■ Ｐ 「留学」□ Y 「技能実習（2号）」□ Ｒ 「特定活動（研究活動等家族）」"Journalist"□ Ｎ「特定活動（本邦大学卒業者）」□ Ｏ 「興行」"Specified Skilled Worker ( ⅱ ) "□ Y 「技能実習（1号）」

Day□ Ｎ 「技術・人文知識・国際業務」"Designated Activities ( Researcher or IT engineer of a designated org)"□ Ｖ「特定技能（2号）」"Specified Skilled Worker ( i ) "

日

1

Month

□ Ｌ「報道」"Religious Activities"□ Ｎ「特定活動（研究活動等）」"Skilled Labor"□ Ｖ「特定技能（1号）」□ Ｋ 「宗教」"Cultural Activities""Researcher (Transferee)"□ Ｎ 「技能」

月

12

Year

Purpose of entry: check one of the followings□ Ｊ 「文化活動」"Artist"□ Ｌ 「研究（転勤）」

年

2030

Date of expiration

11 入国目的 （次のいずれか該当するものを選んでください。）□ Ｉ 「教授」□ Ｉ 「教育」□ Ｊ 「芸術」

有 ・ 無

Accompanying persons, if any

Yes

/

No

VancouverIntended place to apply for visa

17 過去の出入国歴

有 ・ 無Past entry into / departure from Japan
Yes / No
（上記で『有』を選択した場合） (Fill in the followings when the answer is "Yes")

回数

無

・

Canada,Halifax

Home town/city

電話番号"Nursing Care"

MarriedMarital status

8 本国における居住地

Telephone No.

□ Ｎ 「介護」

Day〒612-8577京都市伏見区深草塚本町67龍谷大学グローバル教育推進センター事務部

Address in Japan

Passport

有

6 配偶者の有無

Canada,Halifax

Place of birth

学生（STUDENT）

10 旅券

日

1

Month

Given name

5 出生地

Female9 日本における連絡先

月

1

Year

Anne

Family name

男

4 性 別

年

2003

Date of birth回

1time(s)

直近の出入国歴

18 過去の在留資格認定証明書交付申請歴

年

2022

The latest entry from

7

Year

月

日

1

Month

Day

から
to

2022

年

Year

7

月

Month

10

日

Day

有 ・ 無

Past history of applying for a certificate of eligibility

Yes（上記で『有』を選択した場合）(Fill in the followings when the answer is "Yes")

/

No

回数

回
time(s)回（うち不交付となった回数）（Of these applications, the number of times of non-issuance）

time(s)19 犯罪を理由とする処分を受けたことの有無 （日本国外におけるものを含む。）※交通違反等による処分を含む。
Criminal record (in Japan / overseas)※Including dispositions due to traffic violations, etc.

有 （具体的内容）

Yes ( Detail:

・ 無
/

)

20 退去強制又は出国命令による出国の有無
Departure by deportation /departure order（上記で『有』を選択した場合）(Fill in the followings when the answer is "Yes")

No

有 ・ 無
Yes

回数

/

No

回

直近の送還歴time(s)The latest departure by deportation

年

月

Year

Month

日
Day

21 在日親族（父・母・配偶者・子・兄弟姉妹・祖父母・叔(伯)父・叔(伯)母など）及び同居者
Family in Japan (father, mother, spouse, children, siblings,grandparents, uncle, aunt or others) and cohabitants

有 （「有」の場合は，以下の欄に在日親族及び同居者を記入してください。） ・ 無

Yes (If yes, please fill in your family members in Japan and co-residents in the following columns)

続 柄

氏 名

生年月日

国 籍・地 域 同居予定の有無

Relationship

Name

Date of birth

Nationality/Region/

Intended to residewith applicant or notNo

勤務先名称・通学先名称
Place of employment/school

有・無Yes / No有・無Yes / No有・無Yes / No有・無Yes / No※ 3について，有効な旅券を所持する場合は，旅券の身分事項ページのとおりに記載してください。
Regarding item 3, if you possess your valid passport, please fill in your name as shown in the passport.
21については，記載欄が不足する場合は別紙に記入して添付すること。なお,「研修」，「技能実習」に係る申請の場合は，「在日親族」のみ記載してください。
Regarding item 21, if there is not enough space in the given columns to write in all of your family in Japan, fill in and attach a separate sheet.
In addition, take note that you are only required to fill in your family members in Japan for applications pertaining to “Trainee” or “Technical Intern Training”.

（注） 裏面参照の上，申請に必要な書類を作成して下さい。
Note : Please fill in forms required for application. (See notes on reverse side.)（注） 申請書に事実に反する記載をしたことが判明した場合には，不利益な扱いを受けることがあります。
Note : In case of to be found that you have misrepresented the facts in an application, you will be unfavorably treated in the process.

在留カード番号
特別永住者証明書番号
Residence card number
Special Permanent Resident Certificate number

申請人等作成用 ２

Ｐ （「留学」）

在留資格認定証明書用

For applicant, part 2 P ("Student")

For certificate of eligibility

Place of study
22 通学先(1)名 称
龍谷大学
Name of school(2)所在地(3)電話番号京都市伏見区深草塚本町67

Address

23 修学年数 （小学校～最終学歴）■ 在学中

Graduated□ 高等学校

□ 中学校

□ 大学
□ 小学校
Elementary school

Junior high school

Withdrawal□ 短期大学

Bachelor□ 専門学校Junior college

College of technology□ その他 （）

Others(3)卒業又は卒業見込み年月ABC University

Name of the school□ 中退

Temporary absence□ 大学院 （修士）
Master(2)学校名□ 休学中

In school

DoctorSenior high school

Years

Education (last school or institution) or present school

24 最終学歴 （又は在学中の学校）(1)在籍状況□ 卒業□ 大学院 （博士）年

14Total period of education (from elementary school to last institution of education)

Registered enrollment

075-645-7898

Telephone No.

年

2025

Date of graduation or expected graduation

4

Year

月
Month

25 経歴（直近５年の職歴及び学歴（高等学校卒業以降のものに限る）を記入）

Personal history(Work experience and educational background for the last 5 years (limited to those after graduating from senior high school))

始期

終期

Start

Finish

始期

年

月

年

月

Year

Month

Year

Month

終期

Start

経歴
Personal history

Finish

経歴

年

月

年

月

Year

Month

Year

Month

Personal history

26 日本語能力 （専修学校又は各種学校において日本語教育以外の教育を受ける場合に記入）

Japanese language ability (Fill in the followings when the applicant plans to study at advanced vocational school or vocational school(except Japanese language))
Proof based on a Japanese language test
□ 試験による証明
Name of the test
Attained level or score（１）試験名（２）級又は点数

Organization and period to have received Japanese language education□ 日本語教育を受けた教育機関及び期間
機関名
Organization

期間：
Period

年

月

Year

from

Month

から

年

to

Year

月

まで

月

まで

Month

□ その他
Others27 日本語学習歴 （高等学校において教育を受ける場合に記入）
Japanese education history (Fill in the followings when the applicant plans to study in high school)

日本語の教育又は日本語による教育を受けた教育機関及び期間
Organization and period to have received Japanese language education / received education by Japanese language

機関名

Organization

期間：
Period

年

月

Year

from

Month

から

年

to

Year

Month

28 滞在費の支弁方法等（生活費，学費及び家賃について記入すること。）※複数選択可
Method of support to pay for expenses while in Japan(fill in with regard to living expenses, tuition and rent) * multiple answers possible
Method of support and an amount of support per month (average)(1)支弁方法及び月平均支弁額■ 本人負担30,000Self

円■ 在外経費支弁者負担

Yen

Supporter living abroad□ 在日経費支弁者負担
Supporter in Japan

□ その他

円

Others

Yen

円

■ 奨学金

Yen

Scholarship

50,00020,000

円
Yen

円
Yen

(2)経費支弁者（複数人いる場合は全てについて記入すること。）※任意様式の別紙可
Supporter(If there is more than one, give information on all of the supporters )*another paper may be attached, which does not have to use a prescribed format.

①氏 名
Name

②住 所
Address

SHIRLEY

Aki

5425 Sackville Street, Halifax, Nova Scotia③職業 （勤務先の名称）
Occupation (place of employment)④年 収
Annual income

××University administrative staff

3,000,000

円
Yen

電話番号
Telephone No.

電話番号
Telephone No.

11111111111111

申請人等作成用 ３

Ｐ （「留学」）

在留資格認定証明書用

For applicant, part 3 P ("Student")

For certificate of eligibility(3)申請人との関係 （上記(1)で在外経費支弁者負担又は在日経費支弁者負担を選択した場合に記入）
Relationship with the applicant (Check one of the followings when your answer to the question 27(1) is supporter living abroad or Japan)

□ 夫

□ 妻

Husband

□ 父

Wife

■ 母

Father□ 兄弟姉妹□ 祖父

Mother□ 祖母

Grandfather□ 叔父 （伯父）・叔母（伯母）Brother / Sister

Foster father□ 受入教育機関

Uncle / Aunt

□ 友人・知人の親族□ 養父

Grandmother□ 養母
Foster mother□ 友人・知人

Educational institution

Friend / Acquaintance□ 取引関係者・現地企業等職員

Relative of friend / acquaintanceBusiness connection / Personnel of local enterprise□ 取引関係者・現地企業等職員の親族□ その他 （Relative of business connection / personnel of local enterprise）

Others(4)奨学金支給機関 （上記(1)で奨学金を選択した場合に記入）※複数選択可
Organization which provide scholarship (Check one of the following when the answer to the question 27(1) is scholarship) * multiple answers possible□ 外国政府Foreign government□ 日本国政府□ 地方公共団体

Japanese government

Local government□ 公益社団法人又は公益財団法人 （）

Public interest incorporated association /Public interest incorporated foundation■ その他 （Ryukoku University ）OthersPlans after graduation

29 卒業後の予定■ 帰 国□ 日本での進学

Return to home country

Enter school of higher education in Japan□ 日本での就職□ その他 （Find work in Japan

Others

）30 本邦における申請人の監護人（通学先が中学校又は小学校の場合に記入）
Actual guardian in Japan ( Fill in the following if the applicant is to study at a junior high school or elementary school )(1)氏 名(2)本人との関係

Name

Relationship with the applicant(3)住 所
Address

電話番号

携帯電話番号

Telephone No.

Cellular Phone No.

31 申請人，法定代理人，法第７条の２第２項に規定する代理人
Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.

(1)氏 名(2)本人との関係

Name(3)住 所
Address

電話番号
Telephone No.

〒612-8577 京都市伏見区深草塚本町67
携帯電話番号

075-645-7898

Cellular Phone No.

以上の記載内容は事実と相違ありません。
申請人（代理人）の署名／申請書作成年月日

注 意

受入大学職員Relationship with the applicant

I hereby declare that the statement given above is true and correct.
Signature of the applicant (representative) / Date of filling in this form

年

月

日

Year

Month

Day

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（代理人）が変更箇所を訂正し，署名すること。
申請書作成年月日は申請人（代理人）が自署すること。

Attention

In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant (representative) must correct
the part concerned and sign their name.
The date of preparation of the application form must be written by the applicant (representative).

Agent or other authorized person※ 取次者(1)氏 名Name(3)所属機関等(2)住 所

Address
Organization to which the agent belongs

電話番号

Telephone No.