3‫ֹ׻חץ‬‫ַ׾׺׊‬䑒 釐‫ם‬傴 걉‫יַחמ‬‫־‬‫ג־‬‫ַַֿ־‬‫ׂ׆ֹ׸מ‬‫ֵַף‬ӫ傴 ‫׀‬亠 ‫ئס‬٤‫و‬ٜ宾 㛙‫ ⪌׼־‬㎁‫׾׌‬㕙 ⺬For applicant, part 1

Ministry of Justice, Government of JapanAPPLICATION FOR CERTIFICATE OF ELIGIBILITY
To the Minister of JusticePursuant 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.

Nationality/Region

Family name

YearDate of birth

Given nameMonthDay

NameMaleSex/ Female

Place of birth

Married /Marital status

Occupation

SingleHome town/city

Address in Japan
Telephone No.
Passport

Cellular phone No.
NumberMonthYear

Date of expirationDay

Purpose of entry: check one of the followings"Professor""Instructor""Artist""Intra-company Transferee""Researcher (Transferee)""Engineer / Specialist in Humanities / International Services""Specified Skilled Worker ( i ) ""Technical Intern Training"Cultural Activities""Skilled Labor""Researcher""Student"""Trainee""Technical Intern Training"Spouse or Child of Permanent Resident""Highly Skilled Professional(i)(a)""Long Term Resident""Highly Skilled Professional(i)(b)"Year

Date of entry

Month""Designated Activities(Dependent of EPA)""Designated Activities (Dependent of Researcher or IT engineer of a designated org)""Spouse or Child of Japanese National""Highly Skilled Professional(i)(c)"Day"Journalist""Designated Activities ( Researcher or IT engineer of a designated org)""Entertainer")""Technical Intern Training"Dependent""Business Manager”"Nursing Care""Specified Skilled Worker (""Religious Activities"

OthersPort of entry

Intended length of stay

Accompanying persons, if any

Yes / No

Intended place to apply for visa
Past entry into / departure from Japantime(s)Yes / No
(Fill in the followings when the answer is "Yes")
YearThe latest entry fromMonthDaytoYearMonthDay

Criminal record (in Japan / overseas)
Yes ( Detail:)

Departure by deportation /departure order/No

Yes / No

(Fill in the followings when the answer is "Yes")time(s) The latest departure by deportation

YearMonthDay

Family in Japan (Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents
Yes (If yes, please fill in your family members in Japan and co-residents in the following columns)

Relationship

Name

Date of birth

Nationality/Region

Intended to residewith applicant or not/No

Place of employment/school

Yes / NoYes / NoYes / NoYes / NoRegarding item 20, 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 not required to fill in item 20 for applications pertaining to “Trainee” / “Technical Intern Training”.

Note : Please fill in forms required for application. (See notes on reverse side.)Residence card number

Special Permanent Resident Certificate number3‫ֹ׻חץ‬‫ַ׾׺׊‬䑒 釐‫ם‬傴 걉‫יַחמ‬ׁ‫ׄ׊ ֹס‬؆‫ ׮ מ‬؆ ‫ׄ׊ ׇ‬؆‫ׂ־ׇֹ‬‫׀כ‬ӫ䤗 耆鍱 꽦‫כ‬仼 儖鏤鍱 꽦‫ ⺬מ‬劲‫ג׊‬侇

For applicant, part 2 V ("Specified Skilled Wo ker ( i ) " "Specified Skilled Wo ker () ")For certificate of eligibility

Organization of affiliation of the specified skilled worker
Name of person or organization
Address

Telephone No.
‫ׂ־ׇֹ‬

Skill level‫ש‬؆‫׷‬ֵ‫⺬ֿגם‬ꄇ‫ ס‬operational policy
Proof based on theevaluation method 劲‫⮆ג׊‬
specified in the field-specific

Proof based on the passing of an exam
Name of passed examׁ‫ׄ׊ ֹס‬؆‫ֻױם‬‫־‬䤗耆鍱꽦‫⯥⺲ס‬؅傴ׂն

Proof based on some other evaluation method

Successfully completed Technical Intern Training (ii)Japanese language ability (Fill in this section if you wish to enter Japan with the status of residence of‫ׂ־ׇֹ‬‫ש‬؆‫׷‬Worker (i)")"Specified Skilledꄇ‫ ס‬operational policyֵ‫⺬ֿגם‬
Proof based on theevaluation method 劲‫⮆ג׊‬
specified in the field-specific

Proof based on a Japanese language test
Name of passed examׁ‫ׄ׊ ֹס‬؆‫ֻױם‬ׁ‫ׄ׊ ֹס‬؆‫ׂ־ׇֹ‬‫־‬䤗耆鍱꽦‫⯥⺲ס‬؅傴ׂն‫ֵַף‬䤗耆鍱꽦‫⺬מ‬劲‫׾ַי׊‬㕙⺬‫ע‬

Proof based on some other evaluation method

Successfully completed Technical Intern‫־‬Training (ii)‫׻‬傴‫יׂם־‬荁ַն

Technical Intern Training (ii) that was successfully completed (Fill in this section if you selected "Successfully completed Technical Intern Training (ii) in 22 and 23 above)‫׼ם־‬‫ מ־׿ל‬䑒 ‫׍‬

Occupation / Operations (Fill in the occupation /operations under Appended Table II of the Ordinance for Enforcement of the Acton Proper Technical Intern Training and Protection of Technical Intern Trainees)‫׾׌ؠشؘز‬ն
OccupationOperations
Proof of successful completion

Proof based on passing Grade 3 of the National Trade Skills Test or the practical test of an equivalent technical intern training evaluation exam

Proof based on a document relating to the status of the technical intern training(Fill in (2) if you have several forms of proof)
Occupation / Operations (Fill in the occupation /operations under Appended Table II of the Ordinance for Enforcement of the Act
on Proper Technical Intern Training and Protection of Technical Intern Trainees)

OccupationOperations
Proof of successful completion

Proof based on passing Grade 3 of the National Trade Skills Test or the practical test of an equivalent technical intern training evaluation exam

Proof based on a document relating to the status of the technical intern training

Cumulative period of stay with "Specified Skilled Worker (i)" at the time of submitting this application (including past residence history; fill in this section if you
wish to enter Japan with the status of residence of "Specified Skilled Worker (i))
YearMonth

3‫ֹ׻חץ‬‫ַ׾׺׊‬䑒 釐‫ם‬傴 걉‫יַחמ‬For applicant, part 3 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker () ")For certificate of eligibility

Is there a contract on the collection of a deposit pertaining to the employment contract for a specified skilled worker, or management of other property or the payment of penalties, etc.?

Yes (Name of the organization collecting the deposit or managing property:

Deposit amount or type of property managed:

)

/ No

Do you fully understand and agree on the amount and breakdown of expenses to be paid to the organization in a foreign country
concerning mediation for the application pertaining to the employment contract for specified skilled workers or preparations for activities in
the foreign country? (Fill in this section if there are expenses to be paid.)

Yes (Name of the organization in a foreign country:

Paid expenses and breakdown:)

)

/ No

Have you followed the procedures to be complied with in relation to the activities to be conducted in Japan prescribed by the country or regionof nationality or residence? (Fill in this section if such procedures are prescribed.)

Yes / No

Do you fully understand and have you agreed to the expenses to be paid on a regular basis in Japan? (Fill in this section if there are expenses to be paid.)

Yes / No

Will you endeavor to transfer the skills, etc. you acquire, the skills, etc. for which you increase proficiency or attain proficiency in Japan throughthe technical intern training? (Fill in this section if you have a previous history of residing in Japan with the status of residence of "TechnicalIntern Training", and wish to enter Japan with the status of residence of "Specified Skilled Worker (ii)".)Yes / No

Do you meet the criteria prescribed in the public notice in consideration of circumstances specific to the specified industrial field pertaining toyou? (Fill in this section if such criteria are prescribed.)

Yes / NoEmployment history
Date of joining the company Date of leaving the company

YearMonthYearMonth

Date of joining the company Date of leaving the company

Place of employment

YearMonthYearMonth‫׶׊ַ־‬‫כץ‬

Place of employment‫׊‬؆‫ַ׎‬‫׀כ‬‫־‬⚡炘‫ֿ☔ס‬榼鑁‫׾׿ׂי׊‬侇‫מ‬傴ׂն
(Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.)
Name

Relationship with the applicant

Address

Telephone No.

Cellular Phone No.
I hereby declare that the statement given above is true and correct.
Signature of the applicant (representative) / Date of filling in this formYear‫ֻ׊ ׂ؀ֹכ‬؆ ‫־׀‬؆‫כץ‬Monthׁ‫׊׺׊ ַ׎ֹ׺‬氧ꎰ䶹have䭤嚀
꞊‫☔ס‬
‫׷‬车
Attention In cases where descriptions
changedafterfilling䷓傴in this 㚖‫ֿלם‬application form up until submission of this application, theapplicant (representative)
part concernedand sign their name.
‫׊‬؆‫ ַ׎‬must correct the ‫׀כ‬‫־‬榼鑁‫׾׿ׂי׊‬侇‫מ‬傴ׂնAgent or other authorized person
Name

Address
Organization to which the agent belongs

Telephone No.

Day