Example of entry (with separate
filling-in instructions)

To the Mayor of Edogawa City

◆If you are a corporation, please have your employer fill out the form. ◆The "Parent/guardian entry
section" must be filled out by the parent/guardian themselves.
◆Entries made with an erasable ballpoint pen are invalid. ◆Please print on both sides of the form.
◆Self-employed persons are required to submit a separate "document proving self-employment". For
Employment
certificate
details, pleaserefer to the "Guide to Admission to Approved Childcare Facilities".
Date of certification AD 2023Year 10Office nameMonth4Day

Edogawa-ku Ltd.

If you are self-employed anddo not have a trade name,please enter "no tradename".

Name of representative
Edogawa TaroAddress

1-4-1 Chuo, Edogawa-ku, TokyoTel.

03xxxx

䇷䇷 xxxxName of person in charge Chuo Ichiro
Listed person's contact tel.

070 䇷xxxx

䇷 xxxxI certify that the following information is true and correct.
*If you make or alter the contents of this certificate without the permission of your employer, you may be charged with a crime under the Penal Code.
No.

Item

1

Industry

Furigana

2

Full name of the individual(Planned) Duration of employment, etc.

3

All persons are required to fill out theform.
If self-employed, please indicate the䕕 Agriculture/forestry 䕕 Fishing 䕕 Mining/quarrying/gravel extraction 䕕 Construction 䕕 Manufacturing 䕕 Electricity/gas/heat supply/water supply
date of business commencement.
䕕 Telecommunications 䕕 Transportation/postal 䕕 Wholesale/retail 䕕 Financial/insurance 䕕 Real estate/goods rental
If you are planning to work (offer of䕕 Academic research, professional/technical services 䕕 Lodging/food service 䕕 Lifestyle-related services/entertainment 䕕 Medical/welfareemployment), please indicate the date
䕕 Education/learning support 䕕 Complex service 䕕 Official business 䕕 Other䠄䠅
you plan to start working.
Entry section

Edogawa Hanako

Date of Birth 1982 YYYY 7 MM

Edogawa Hanako

Period䕕 Indefinite 䕕 Definite
term

2016 YYYY(If the term is indefinite, only the employment start date)

4MM1D䡚

YYYYMM

3

DD

Enter the hours on your employment
Edogawa Funabori Ekimae Branch
4 Place of employment
contract.
Address△-Chome, O-Ban, O-Go, Funabori, Edogawa-ku, Tokyo
If you are using the shortened working
䕕 Full-time employee 䕕 Part-time job 䕕 Temporary worker 䕕Contract employee 䕕 Fiscal year appointed staff 䕕Part-time and temporary staff 䕕 Executive
hours system for childcare, please
5Form of employment
䕕 Self-employed 䕕 Self-employed professional 䕕 Family worker 䕕 Side job 䕕 Outsourcing 䕕 Other ()enter
the hours before the shortened
Mon Tue Wed Thu Fri Sat Sun National holiday Totalhours.
includes minutes
Monthly 180
hours 0 minutes䠄of break time 1200 minutes䠅
hours
In the case of a flextime or discretion䕕䕕 䕕 䕕 䕕 䕕 䕕 䕕
ary work system, enter standard work
Workingdays
permonthMonthly
Workingdays
perweek
WeeklyDayDay20
Number of hours workedhours.
(For fixed employment)
Weekdays830
1730
䡚䠄 includes minutes of break time 60 minutes䠅
::*Please fill in the form with "24-hour::
Saturday830
1730
䡚䠄 includes minutes of break time 60 minutes䠅
6notation".
Sunday andName:national holiday

Total hours
Number of hours worked Number of days worked(For flexible work)

Work record

7*Number of days includes paid vacations, andnumber of hours includes breaks and overtime

Acquisition of leave pre-natal/
post-natal maternity

8*Including planned acquisition䕕 Weeklyhours

䕕 Monthly䕕 WeeklyDay

Main working hours
and shift hours

Year/Month21:

䡚䕕 Monthly:䠄 includes minutes of break timeminutes䠅minutes 䠄 includes minutes of break timeminutes䠅

:

䡚

2022

Year 3MonthYear/MonthDay/month

195

Hours/month

10

2022

YearDay/month䠄 includes minutes of break time
2200

MonthYear/MonthHours/month202022 Year

Day/monthIf the number of days worked, hours
worked, or days worked areminutes䠅
irregular, please attach a shift table
1 Month(for the last three months).

190 Hours/month䕕 Scheduled 䕕 Now taking

PeriodYYYYMMD䡚D䡚YYYYMM

DPlease include the number of paidvacation days taken and holidays
worked.
䠅Acquisition of leave other than 䕕 Scheduled 䕕 Now taking 䕕 Acquired Reason 䕕 Nursing care leave 䕕 Sick leave 䕕 Other䠄If you are on maternity leave before
10 maternity or childcare leave
PeriodYYYYMMD 䡚YYYYMMDor after childbirth or childcare leave,Plans to return2024
613
䕕 Already returned to work
11 Date of (planned) return to work 䕕 to workYYYYMM
Denter the last three months prior toyour maternity leave.
䕕Scheduled䕕NowtakingPeriod
䡚
2025
331
2024
613
YYYY
MM
D
YYYY
MM
D
Availability of short-time
If you have just recently started work
12 working system for childcare Main working hours
30::
30
1660 minutes䠅
9䡚
䠄includes minutes of break time
*Including planned acquisition and shift hours
and you have less than threemonths of work experience, please
Work experience situation
䕕 Yes 䕕 Yes (planned) 䕕 None
13
enter as much as has been
as a childcare worker
determined. Not required if you havean employment offer.
of childcare leave
9 Acquisition*Including planned acquisition

14

䕕 Scheduled 䕕 Now taking 䕕 Acquired

Period2022

YYYY

812MM2024

YYYY

6MM

12Remarks column

Additional fields of entry
15

transfer away
䕕 Yes
Employment situation Job
from home

䕕 NonePlease fill in if you are
expecting to give birth or areon maternity leave.

(Planned) Placeof assignment

Please enter the "actual" hours actually worked/the "actual amount paid."

16DRecentwork
recordYear/Month ϸ 2022 YYYY 3M

Ϲ 2022 YYYY 2M

Ϻ 2022 YYYY 1

M

Number of days worked

D19

D20

D21

*Including paid holidays

Salary payment record

If you are undecided about
using the short-time work
system, you may leave thisblank.

266,000

Yen

273,000

Yen

For self-employed persons,please enter the amountexcluding necessary
expenses.
If not yet determined,
please enter an approximate amount.

260,000

Yen

Fixed salary(Monthlyamount)Monthly amount under the employment contract,
not the amount of salary actually paid

250,000

Yen

Enter the amount of salary (before deduction oftaxes, social insurance premiums, etc.) that does
not fluctuate each month, excluding bonuses,
lump-sum payments, commuting allowances, andovertime allowances. Qualification, position andregional allowances are included. *If you work
shorter hours, enter the amountEntry column forparents/guardians<Entry column for parents/guardians> Please have a parent/guardian fill out this form.
Name of child
Edogawa Kisaku

Name of child

Date of Birth2022 YYYYIn use
4MM13D

Date of Birth
YYYYFacility
nameIn use

MMD

Transfer

Applied (first choice)If you are applying for ażż1XUVHU\6FKRROTransfer

Applied (first choice)

Facilitynamechildcare facility, please fill in
the name of your first choice.

[Note on entry] *Please be sure to read this information as it is very important. If you have any questions, please contact the departments below.
(1) This certificate is issued by a company or other entity to certify the employee's employment status. The certification will be invalidated if it is written by
the parent/guardian himself/herself, except for private business owners, etc.
䚷Those without a certification date (within 3 months of the application date) will also be considered invalid.
(2) If you make a false statement or forge or falsify a certificate, you may be criminally liable for forgery of a sealed private document, Article 159 of the Penal Code.
䚷 In addition, the certification and acceptance decision will be cancelled. Please be advised that our staff may call or visit you to confirm the details of the certification.
䚷(3) Please cross out any corrections with a double line. However, certifications made with erasable ballpoint pens or pencils or with the use of correction fluid or
correction tape will be considered invalid.
(4) If any violation of laws and regulations is found in working conditions, etc., the Labor Standards Inspection Office may be notified, depending on the circumstances.
(5) Please fill in the work record for the three months prior to the leave if you are taking maternity or childcare leave, or to the extent that the record has been finalized if
the record is less than three months immediately after the start of employment.
(6) If you are self-employed and applying for admission to a childcare facility (continued) or for entrusted care of a childcare provider infant (continued), please attacha copy of your tax return or a notification of business opening to confirm the details of your tax return.
Childcare Section, Department of Children and Family Affairs, Edogawa Ward Tel: 03-5662-0066 (direct line),
Childcare Provider Section Tel: 03-5662-0072 (direct line), Childcare Support Section, Facility Use Benefits Section Tel: 03-5662-1012 (direct line)䕦
Example of a completed
certificate form(Ward website)