3‫ֹ׻חץ‬‫ַ׾׺׊‬䑒 釐‫ם‬傴 걉‫יַחמ‬‫־‬‫ג־‬‫ׂ ־ ׊ ֹ׸׽ַ׉‬‫׫‬؆‫ֹ׆‬‫ֵַף‬ӫ傴 ‫׀‬亠 ‫ئס‬٤‫و‬ٜ㏇ 槳鞲 劲؅㚺 催‫׾׌‬㕙 ⺬

For applicant, part 1

Ministry of Justice,Government of JapanAPPLICATION FOR CHANGE OF STATUS OF RESIDENCE
To the Minister of JusticePursuant to the provisions of Paragraph 2 of Article 20 of the Immigration Control and Refugee Recognition Act,I hereby apply for a change of status of residence.

Nationality/Region

Year

Date of birth

Family name

Given nameMonthDayNameSexMale/Female

Place of birthOccupation

Married / Single

Marital status
Home town/city

Address in Japan
Telephone No.
Passport

Cellular phone No.
NumberYear

Date of expiration

Status of residenceMonthDay

Period of stayYear

Date of expiration

MonthDay

Residence card number
Desired status of residence
Period of stay

( It may not be as desired after examination.)

Reason for change of status of residence
Criminal record (in Japan / overseas)
Yes ( Detail:)/No

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

Residing withapplicant or not/No

Place of employment/ school

Residence card number
Special Permanent Resident Certificate number

Yes / NoYes / NoYes / NoYes / NoYes / NoYes / No

16
Regarding item 16, 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 16 for applications pertaining to “Trainee” or “Technical Intern Training”.

Note : Please fill in forms required for application. (See notes on reverse side.)3‫ֹ׻חץ‬‫ַ׾׺׊‬䑒 釐‫ם‬傴 걉‫יַחמ‬ׁ ‫ֹ׸׊ז׋ ֹ ס‬‫ׇֹ‬‫ֹ׆ֹ׺׽‬‫ֹ׺׽ֹ׸׊‬‫׀כ‬ӫ䤗 耆㲔 綗⺘ ؅荁 㞐‫ג׊▼ ⟣מ‬侇For applicant, part 2 V ("Specified Skilled Wo ker ( i ) " "Specified Skilled Wo ker () ")For change of status

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

Telephone No.

Skill level
Proof based on the evaluation method specified in the field-specific operational policy

Proof based on the passing of an exam
Name of passed exam‫ؠشؘزמ׆׆‬؅‫׾׌‬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 reside in Japan with the status of residence of "Specified Skilled Worker (i)")
Proof based on the evaluation method specified in the field-specific operational policy

Proof based on a Japanese language test
Name of passed exam‫ؠشؘزמ׆׆‬؅‫׾׌‬ն

Proof based on some other evaluation method

Successfully completed Technical Intern Training (ii)Technical Intern Training (ii) that was successfully completed (Fill in this section if you selected "Successfully completed Technical Intern Training (ii) in 18 and 19 above)

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 trainingׁ‫ֹ׸׊ז׋ ֹס‬‫׺׊ף‬ֽ‫ם‬(Fill in (2) if you have several forms of proof)䤗耆㲔綗‫גַי׊‬㕙䢥‫׋⺱כ‬‫׺׊ף‬‫׼גע‬‫ֵַף‬‫׺׊ֹ׺ה־ֹ׺ץ‬Occupation / Operations (Fill in the occupation /operations under Appended Table
II of the⥸Ordinancefor Enforcementof 傴‫ס‬
the Act㕙䢥‫ך‬ׂ㕙⺬‫עמ‬鍐❫鐧
on Proper Technical Intern Training and Protection of Technical Intern Trainees)‫ח׸׊ַי‬OccupationOperations
Proof of successful completion䬠⭳؅‫ַ׻יׂם׊‬ն

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 "Technical Intern Training (i)" at the time of submitting this application (including past residence history; fill in this section if youwish to reside in Japan with the status of residence of "Specified Skilled Worker (i))
YearMonth

3‫ֹ׻חץ‬‫ַ׾׺׊‬䑒 釐‫ם‬傴 걉‫יַחמ‬ׁ ‫׸׋ַ׌ ֹ ס‬؆ֽ‫׻‬‫ ׮ מ‬؆ ‫׸׋ַ׌ׂ׺׽ֹס ׇ‬؆‫ׄ׊‬؆‫ַ״ֹ׺׊‬‫ֵַף‬ӫ䤗 耆姡 嶖 ⹕ ‫צ‬仼 儖鏤耆 ⱱ 姡 嶖؅鍱 꽦‫׽׻מ‬錞 伺‫׾׌‬㕙 ⺬
For applicant, part 2 V ("Specified Skilled Wo ker ( i ) " "Specified Skilled Wo ker () ")For change of status

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

Telephone No.

Skill level‫׈ַיׂכ‬؆ׁ‫ש ֹ׺‬؆‫׷‬ׁ‫שׂ ׳ֹ׺‬؆‫ד׈‬攐㲊榤哅⮆ꄇ‫ס‬哅ⳉ⵱⮆‫מכׇ‬㲊‫׼״‬

Proof based on the evaluation method specified in the field-specific operational policy

Proof based on the passing of an exam
Name of passed examׁ‫ׄ׊ ֹס‬؆‫ֹ׺׊ַ״‬‫ַ׈׀‬‫׾ַי׿‬䤗耆鍱꽦‫⺲ס‬燡؅鋗鬼‫׾׌‬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 reside in Japan with the statusof residence of "Specified
Skilled Worker (i)") ‫ד׈‬‫׈ַיׂכ‬؆ׁ‫ש ֹ׺‬؆‫׷‬ׁ‫שׂ ׳ֹ׺‬؆

Proof based on the攐evaluationin thefield-specificoperational policy
㲊榤method哅⮆specifiedꄇ‫ס‬哅ⳉ⵱⮆‫מכׇ‬㲊‫׼״‬

Proof based on a Japanese language test
Name of passed examׁ‫ׄ׊ ֹס‬؆‫ֹ׺׊ַ״‬‫ַ׈׀‬ׁ‫׸׋ַ׌ ֹס‬؆‫ֹכ‬‫ַ״ֹ׺׊‬‫׾ַי׿‬䤗耆鍱꽦‫⺲ס‬燡؅鋗鬼‫׾׌‬ն‫ׄ׊‬؆ ‫ֹכ‬鍱꽦璡‫׽׻מ‬䤗耆姡嶖璡؅錞伺

Proof based on some other evaluation method‫ֹ׻ר ַ׈׀ ֵַף‬Successfully completed Technical InternTraining⺬յ(ii) 鋗鬼┘釐ն‫׾׌‬㕙

Technical Intern Training (ii) that was successfully completed (Fill in this section if you selected "Successfully completed Technical Intern Training (ii) in 18 and 19 above)‫( ׼ם־‬Fill in the occupation /operations under Appended Table II of the Ordinance for Enforcement of the Act
Occupation / Operationsַ‫ מ־׿׍‬䑒 ‫׍‬on 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 youwish to reside in 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 change of status

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 reside in Japan with the status of residence of "Specified Skilled Worker (ii)".)Yes / NoDo 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 / No

Employment history
Date of joining the company Date of leaving the company

YearMonthYear

Date of joining the company Date of leaving the company

Place of employment

MonthYearMonthYear

MonthPlace of employment

Legal representative (in case of legal representative)
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 (legal representative) / Date of filling in this form

Year

MonthAttention In cases where descriptions‫ׂ؀ֹכ‬‫ֻ׊‬؆‫־׀‬؆‫ כץ‬inׁ‫ַ׎ֹ׺‬‫ ׊׺׊‬form up until submission of this application, thehavechanged
after filling
this application氧ꎰ䶹꞊‫☔ס‬䷓傴applicant (legal representative)
must䭤嚀correct
the part ‫׷‬车concernedand㚖‫ֿלם‬sign their name.
‫׊‬؆‫ַ׎‬‫׀כ‬‫־‬榼鑁‫׾׿ׂי׊‬侇‫מ‬傴ׂնAgent or other authorized
personNameAddress

Organization to which the agent belongs (in case of a relative, relationship with the applicant)Telephone No.

Day