【Work Certificate】Guide to filling out the form
Date of certificationi Cn ef ro tr im fa it ei ro ’n s№1№2Office Name

*Make sure to refer the entry example.
*Use the Western calendar for the date and year column.
Provide the date of certification (Date the certificate is issued).
Provide the name of the legal entity / company / organization (dispatching or seconding company etc.) which is responsible forissuance of the certificate.
If the certifier is a sole proprietor, provide the business name. In case he/she doesn’t have any business name, indicate thetrade name or full name of the sole proprietor him/herself.

Name of Representative

Provide the full name of the person who has authority to certify the certificate and is responsible for the certificate’s contentssuch as a representative director, HR department chief, branch manager.

Address

Provide the address of the office issuing the certificate.

TEL

Provide the telephone number of the office issuing the certificate.
Provide the name and phone number of the contact person to receive administrative communications.
If the applicant worker is an employee and involved in the business of issuing certificates, someone other than him/herneeds to certify the certificate and provide the name.

Name of the person incharge／Contact
Type of Business
its Katakana spelling／
Name of the applicant
Date of Birth№3

Employment (planned)
period, etc.

№4

Company where theapplicant works№5

Type of Employment

Mark check (✓) on an applicable item which describes the current working situation.
Provide the applicant worker’s full name and its Katakana spelling.
Provide the applicant worker’s birthdate.
Mark check (✓) on either “□Indefinite” or “□Fixed term”.
In case of “□Indefinite”, provide only the start date of employment.
In case of “□Fixed term”, provide the period and mark check (✓) on either “□Yes” or “□No” on the column No.16
below.
In case the business office is different from the one indicated on the upper right column, provide the office’s name and location
where the applicant worker is actually working.
Mark check (✓) on an applicable item.
Self-employed refers the cases where the applicant worker is the owner him/herself, working for a business run by anotherfamily member within the second degree of kinship.
For those who are self-employed are also required to prepare for a certificate of self-employment such as a true copy of acompany register and documents proving earnings such as tax return, among others.
Mon～ Public holidays

Total hours
Working hours(For fixed employment)
Number of working days
per month/
Number of working days
per week
Weekdays ・ Sat/Sun・ Public holidays№6

Total hours
Working hours(in case of irregular work)
Number of working days

Mark check (✓) on applicable items which describe the usual working days.［multiple choice
allowed］
This refers the working hours based on the employment contract, but NOT the actual working
hours (record).
Since it is working hours based on the employment contract, do not include over time.
As for break time, include only the one stipulated in the work regulations.
Even in case the applicant worker is working under the shortened working hour system for childcare,provide working hours before using the system.
Number of days per month: If the number of the days per week is fixed, multiply it by 4 (weeks) toprovide the number.
Number of days per week: If the number of the days per month is fixed, divide it by 4 (weeks) toprovide the number.
For the working time, provide it in the 24 hour-notation. If the work spreads across 2 days due tonight shift etc., provide in the range of 0 to 29 (ex.: Enter “22:00 to 29:00” if the work is from 10pm
to 5am of the following day).
Provide the time following the note for the “Total hours” column of the “Working hours (Forfixed employment)”.
If the working hours per day are fixed, multiply it by the number of working days in a week to provide“weekly” working hours.
If weekly working hours are provided, we calculate the deemed monthly working hours by multiplying
it by 4
Provide the information about the number of working days per month or week.
If the number of working days per year is fixed, divide it by 12 (months) to provide the number ofworking days per month, while by 48 (weeks) to provide the number of working days per week.

For the working time, provide it in the 24 hour-notation.
Main working hours/shift
Provide the applicant worker’s most typical working hours regarding the main work shift.
hours

№7

Work record

Provide the actual record for the recent 3 months.
Include paid leave in the number of days, break time and over time in the number hours respectively.
It is not required to fill up this space if the applicant worker does not have any actual record due to new employment etc.
If any of No.8, 9 or 10 applies, provide the details before and after excluding the period in question.
If the applicant worker started taking any of No. 8, 9 or 10 from the middle of the month, provide the details of themonths before and after excluding the month in question.
If the applicant worker is working under the shortened working hour system for childcare, provide the actual work record underthe system.
Mark check (✓) on either “□Scheduled to acquire”, “□Acquiring” or “□Acquired”.
If the parent/guardian already has returned to the work, provide actual record of acquisition (No need to fill up if 1 year or
more has passed since the worker came back from the leave.).
Provide the end date even if it is not finalized.
Regardless of the admission month to the daycare center, provide the period coordinated by both the company and theapplicant worker who is the parent/guardian.
If more than one applies, provide the most recent here, and past acquisitions in the remarks column.
Fill up in accordance with the Act on the Welfare of Workers Caring for Children or Family Care such as Childcare leave andNursing Care leave and the Labor Standard Act, or collective contract, work regulation and labor contract based on the said
acts.

№8

Taking prenatal andpostnatal leave№9

Taking childcare leave№10

Mark check (✓) on applicable cause of acquisition of a leave other than maternity leave and childcare leave.
Taking leave other than
Indicate about the leave which the company approved.
maternity/childcare leave№11(Planned) date ofreinstatement№12

Availing the shortened
working hour system forchildcare

Mark check (✓) on “□Scheduled to return to work” and provide the schedule return date if the applicant worker is scheduled
to return to work.
Mark check (✓) on “□Returned to work” and provide the return date if he/she has returned from the childcare leave etc.
which he/she took within the past 1 year.
Mark check (✓) on “□Scheduled to acquire” or “□Acquiring” if the applicant worker is using the shortened working hoursystem for childcare.
No need to fill up if he/she is not going to use it.
Provide the period / planned period of availing the system and main working hours (working hours after changing the workschedule).
Provide the number of working days after starting the shortened working hour system on No.17.

№14

Whether or not you
actually work as achildcare worker, etc.
Remarks column№15Single/Overseas
Mark check (✓) on either “□Yes” or “□No”. If “□Yes”, provide the period.
assignment*Includes plans№13№16№17

There is a ☑ in No.3
fixed term
→ whether the contract
will be renewed or not
Number of workingdays(planned) for those
who falls under No.12

Mark check (✓) on either “□Yes”, “□Yes (Scheduled)” or “□No”.
Provide other special remarks if any.

Mark check (✓) on either “□Yes” or “□No” regarding the contract renewal schedule, if the employment contract is fixedterm.
Make sure to fill up this part if No.12 applies.
Provide the number of working days per month or week after starting the shortened working hour system.