Questionnaire (for application for certificate of eligibility and change)
This questionnaire serves as a reference material in the examination of an application.
レ or ○) the applicable items and be as specific and detailed as
Please check or circle (□possible when providing written responses. The spouse must complete this questionnaire
independently and without the assistance of any other person.
Any statements in this questionnaire which are found to be contrary to the facts will
prejudice the applicant's examination treatment and may result in criminal charges.
Therefore, please confirm that your answers contain no mistakes before you independently
sign and submit this questionnaire.
[Notes]* Applicant (your partner) refers to a foreign national subject to examination in order toenter or stay in Japan (a foreign national wishing to stay in Japan).
* Spouse (you) refers to a Japanese or foreign national married to the applicant.

1. Enter the statuses of the applicant and the spouse. A katakana pronunciation of thekanji should also be provided for the name of a Japanese national.
Nationality
Applicant

Name

Name

MaleFemale

Katakana pronunciation

Nationality

Address

SpouseResidence

TEL

Other

Home telephone no.

□Nocohabitants□ Own house

Mobile telephone no.

□Yes (Name(s)□ Rented house)
RentCompanyyenLDK

Job description

Workplace

nameAddress
TEL

Date hired

YY- 1/8 -MMDD

2. Developments leading to the marriage(1) Enter the date and place that you first came to know each other and developments
leading to the marriage.
(i) Date:

YYMMDD

Place:(ii) Explain the developments leading to the submission of the marriage registration in
as much detail as possible, citing specific dates from the time that you first met.
If the space provided is insufficient, you may use additional pages as necessary.
You may also attach relevant photos and letters as well as documents proving
international calls.

- 2/8 -(2) Existence of an intermediary□ No□ Yes (In the case of marriage arranged by a marriage agency, provide theagency's name and details below.)
Intermediary
Nationality:
Name:(Male / Female)

Date of birth:

YYMMDD

Address:
TEL:
Residence Card No. (for a foreign national)
Date, place and method of introduction
Date:

YYMMPlace:
Method:□ Photo □ Telephone □ Meeting□ Other (Relationship between the intermediary and the applicant (in detail):DD□ Email)

Relationship between the intermediary and the spouse (in detail):* The relationship should be explained in detail, rather than merely stating that theintermediary is a friend or acquaintance.
3. Language used by the couple(1) What language do you usually use in conversation with your husband or wife (e.g.,Chinese, Japanese, etc.)?

(2) What is your mother tongue?
(i) Applicant:(ii) Spouse:- 3/8 -(3) To what extent does the applicant understand your mother tongue?
□ Difficult / Need an interpreter □ In writing / Only simple greetings□ Only everyday conversation□ Fluent(4) To what extent does the spouse understand the mother tongue of the applicant?
□ Difficult / Need an interpreter □ In writing / Only simple greetings□ Only everyday conversation□ Fluent(5) If the applicant understands the Japanese language, provide specifically when and how
he/she learned it.

(6) When you are unable to make yourselves understood in any language, how do youcommunicate?
[Method]:[If an interpreter was or is being used](i) Interpreter's name:(ii) Interpreter's nationality:(iii) Interpreter's address:

4. Provide information on the two witnesses who signed your marriage registration inJapan.
(1) Name:(Male/Female)

Address:
TEL:(2) Name:(Male/Female)

Address:TEL:- 4/8 -5. If you held a wedding ceremony (wedding reception), enter the date and location,
etc.
Date:

YY

MMDD

Location:
Attendants:
Applicant: Father

Spouse:MotherOlder brother(s)Younger brother(s)Older sister(s)Younger sister(s)ChildrenFather

Older brother(s)Younger brother(s)Younger sister(s)Children□ Remarriage (nd/rd/th marriage)

MotherOlder sister(s)Total number of attendees:

6. Marital history
Applicant: □ First marriage

Previous marriage
YYMMDD toYYMMDD(Marriage terminated by □ Legal proceeding (divorce, annulment, etc.)□ Death of spouse)
Spouse: □ First marriage□ Remarriage (nd/rd/th marriage)

Previous marriage
YYMMDD toYY
MMDD(Marriage terminated by □ Legal proceeding (divorce, annulment, etc.)□ Death of spouse)
7. If the applicant has visited Japan, provide the number of times and periods.
(1) Number of times:times(2) Periods

Purpose (Sightseeing, job, etc.)(i)

YYMMDD toYYMMDD ()(ii)YY

MMDD toYY

MMDD ()(iii)YY

MMDD toYYMMDD ()

(iv)

YY

MMDD toYY

MMDD ()(v)

YY

MMDD toYY

MMDD ()* Enter the five most recent visits to Japan if the applicant has visited more than fivetimes.

8. If the spouse has visited the applicant's home country, provide the number of timesand periods.

- 5/8 -(1) Until marriage (from the time you first met) (times)

(i)

YY

MMDD toYY

MMDD ()(ii)

YY

MMDD toYY

MMDD ()(iii)YY

MMDD toYY

MMDD ()(iv)

YY

MMDD toYY

MMDD ()(v)

YY

MMDD toYY

MMDD ()* Enter the five most recent visits to the applicant's home country if the spouse has visited
it more than five times.
(2) After marriage (times)

(i)

YY

MMDD toYY

MMDD ()(ii)

YY

MMDD toYY

MMDD ()(iii)YY

MMDD toYY

MMDD ()(iv)

YY

MMDD toYYMMDD ()(v)

YYMMDD toYYMMDD ()* Enter the five most recent visits to the applicant's home country if the spouse has visited
it more than five times.

9. Has the applicant ever been forcibly deported from Japan (including under adeparture order)?
□ No□ Yes (times)
10. For an applicant answering in the affirmative to Question 9 above(1) Details of the violation□ Illegally stayed beyond the period of stay (Overstay)□ Illegal entry (via smuggling, use of fake passport, etc.)□ Other ()(2) Date and airport of most recent deportation
Date:

YYMMDDfromAirport(3) Are the nationality, name and date of birth stated in this application the same as thosestated in the applicant's passport at the time of his/her most recent deportation?
□ Same□ Different name, etc. Nationality:
Name:
Date of birth:
YY
MMDD- 6/8 -(4) If you had lived together with your spouse in Japan before his/her deportation, entersaid period and address.
Period:YY

MMDD toYYMMDD

Address:

11. Relatives of the applicant and the spouse* Provide telephone numbers of relatives residing in Japan if possible. If your parents
have passed away, enter "Deceased" in the address column. Enter information about
your children in table (2) below. If you do not have any children, enter "None."(1) Enter information about your parents, brothers and sisters.
Relationship

Name

AgeAddress

TEL[Example]
FatherTaro Nyukan

62 1-2-301, ××, Chiyoda-ku, Tokyo

03-▽△-××××

Nyukan James V.

62 New York, U.S.A (city name)××××-12-○○-345

FatherHusband's relatives

Mother[Example]
FatherFatherMother
Wife's relatives- 7/8 -(2) Enter information about your children.
Name

Relationship

Date of BirthAddress[Example]
Husband's

Saburo Nyukan Nov. 19, 1975 9-8-7, ××, Saitama-shi, Saitama

eldest son
Wife's eldest Nyukan Mary C Dec. 15, 1999 New York, U.S.A (city name)daughter

12. Which of your relatives know of the marriage? (Circle all applicable relatives)
Husband's side: Father

Wife's side:

MotherOlder brother(s)Younger brother(s)Older sister(s)Younger sister(s)ChildrenFather

Older brother(s)Younger brother(s)Younger sister(s)ChildrenMother

Older sister(s)The above statements contain no mistakes.
YYMMDD

Signature (Spouse):(NOTE)
Any statements in this questionnaire which are found to be contrary to the facts will
prejudice the applicant's examination treatment and may result in criminal charges.
Therefore, please confirm that your answers contain no mistakes before you independently
sign and submit this questionnaire.

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