パソコンで入力できます
Employment certificate

To the Mayor of Edogawa City

Date of certification ADYearMonthDay

Office nameName of representativeAddressTel.

――――

Name of person in charge
Listed person's contact tel.

I 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.
ItemNo.

Entry section□ Agriculture/forestry □ Fishing □ Mining/quarrying/gravel extraction

12Industry□ Telecommunications □ Transportation/postal □ Wholesale/retail□ Academic research/professional/technical services□ Lodging/food service□ Education/learning support □ Complex service□ Official business□ Lifestyle-related services/entertainment□ Medical/welfare□ Other（）

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

4Place of employment

5

Form of employment

Date of Birth□ Indefinite □ Definite
termPeriod□ Self-employed □ Self-employed professional □ Family worker □ Side job □ Outsourcing
Totalhours

MonthlyMonthlyDay

Working days per week:～:

Saturday:～

Sunday andnational holiday:～□□□Number of hours worked Number of days worked

Work record

Acquisition of leave pre-natal/
post-natal maternity*Including planned acquisitionof childcare leave
9 Acquisition*Including planned acquisition□□□ Monthly□ Weeklyhours□ Monthly□ WeeklyDay

Main working hours
and shift hours

Year/Month□

□

:
Year

MonthDay/monthYear/MonthHours/monthPeriod

YYYY

Remarks column

includes minutes

minutes（of break time
Weeklyminutes）

Dayminutes）:（ includes minutes of break timeminutes）:（ includes minutes of break timeminutes）

minutes （ includes minutes of break timeminutes）（ includes minutes of break timeminutes）

Year/MonthMonthMonthDay/monthHours/monthYear

Day/monthHours/monthD～YYYYMM

DD～

YYYY

MM

DMM

D

□ Scheduled □ Now taking □ Acquired

Period

YYYY

MM

YYYY

DPlans to return□ to work□ Already returned to work

□ Yes

□ Yes (planned)□ Nursing care leave □ Sick leave □ Other（MM:MMYYYY

DMMD～:～）

YYYY～

YYYY

Period*Including planned acquisition and shift hours14)（ includes minutes of break timeYearMM□ Scheduled □ Now taking
Availability of short-time
12 working system for childcare Main working hours

Work experience situation
as a childcare worker

D□ Scheduled □ Now taking

Acquisition of leave other than
10 maternity or childcare leave
Period13MM□ Other (hours:～□ Scheduled □ Now taking □ Acquired Reason

11 Date of (planned) return to workD□ Full-time employee □ Part-time job □ Temporary worker □Contract employee □ Fiscal year appointed staff □Part-time and temporary staff □ Executive

Total hours*Number of days includes paid vacations, andnumber of hours includes breaks and overtimeYYYYMMName

Number of hours worked Working days per month(For fixed employment)
Weekdays(For flexible work)

D～MM

YYYYAddress□6

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

Mon Tue Wed Thu Fri Sat Sun National holiday

8□ Manufacturing □ Electricity/gas/heat supply/water supply

Furigana

37□ Construction□ Financial/insurance □ Real estate/goods rental

YYYY（includes minutes of break timeMMDminutes）□ NoneAdditional fields of entry15transfer away
□ Yes
Employment situation Jobfrom home

□ None(Planned) Placeof assignment

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

16Recentworkrecord

Year/Month ⅰ

YYYYMⅱYYYYMⅲ

YYYY

M

Number of days worked

DDD

Salary payment record

Yen

Yen

Yen

*Including paid holidays

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

Yen

Entry column forparents/guardians<Entry column for parents/guardians> Please have a parent/guardian fill out this form.
Name of child

Date of BirthYYYY

Name of childIn useMMD

Date of Birth
YYYYD

Applied (first choice)Transfer

Applied (first choice)

Facilityname
In useMMTransfer

Facilityname[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.
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.
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.
(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 orcorrection 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)▲
Example of a completed
certificate form
(Ward website)