参考様式第１－１号
Reference Form 1-1

特 定 技 能 外 国 人 の 履 歴 書
CURRICULUM VITAE OF THE SPECIFIED SKILLED WORKER
①Name

Roman

Male / Female② Sex

letters
Kanji

DD/MM/YY③ Date of birthcharacters④Nationality (country or⑤ Reasonably

region)fluent languages⑥Address in the country（Tel:of origin or country of

－

－

）

residence

Year

Month

Year

Month

Most recent educational background/ main occupations⑦Educational
background/ occupational
history⑧Qualifications/licenses

Status of residence

Organization of affiliation, etc.

Supervising organization⑨If you have previously
resided in Japan with thestatus of residence of“Technical Intern Training”,
give your residence
history.

Notes.
Section ①. Write the name exactly as given in the passport in Roman letters, and if there is a name in kanji characters, give it
together with the Roman letters.
Section ⑤. Write the languages that the specified skilled worker is able to sufficiently understand (native language and others).
Section ⑨. Describe in detail the periods of residence in Japan with the status of residence of “Technical Intern Training”, theimplementing organization of the technical intern training, and the supervising organization (only in cases ofsupervising-organization-type technical intern training).

I hereby declare that the statement given above is true and correct.
Prepared on DD/MM/YYYY
Signature of the specified skilled worker

参考様式第１－３号
Reference Form 1-3

健

康

診

断

個

人

票

HEALTH CHECK REPORT
Date of health

Date of birth DD/MM/YYYY
Sex
Work history

Male / female

Age

Blood pressure
Anemia test

DD/MM/YYYY

check

Name

years
（mmHg）

Hemoglobin level（g/dℓ）

Red blood cell count(10,000/mm³)
Past history

Liver function GOT
test

GPT

（IU/ℓ）（IU/ℓ）

γ - GTP （IU/ℓ）
Subjective symptoms

Blood lipid
examination

LDL cholesterol（mg/dℓ）
HDL cholesterol（mg/dℓ）
Triglyceride（mg/dℓ）

Objective symptoms

Blood glucose test
Urinalysis（mg/dℓ）GlucoseProtein

Height (cm)Weight (kg)Electrocardiographexamination
Other examinations

BMI

Physician’s diagnosis

Waist circumference(cm)
Eyesight

Hearing

Right

（

）

Left

（

）

Right

１ Normal

２ Impaired

1,000Hz

１ Normal

２ Impaired

4,000Hz

Remarks

Left

１ Normal

２ Impaired

1,000Hz

１ Normal

２ Impaired

4,000Hz
Tuberculosis,

Chest X-ray

DirectIndirect

etc.

examination

Taken

DD/MM/YYYY

No.
Film no.

Findings:

Notes.

1. The BMI is calculated using the following formula.

Body weight(㎏)Height(m)²2. In the column of “Eyesight”, write the number outside the parentheses ( ) if it has not been corrected,
and inside the parentheses ( ) if it has been corrected.
3. If abnormal findings are found in the “Chest X-ray examination” section, conduct a sputum
examination and confirm there is no active tuberculosis.
4. In the “Physician’s diagnosis” section, fill in the physician’s diagnosis such as no abnormality, detailed
examination required, medical examination required, etc.
5. If a disease is currently being treated, describe the medical condition which needs to be noted medically,such as the current medical history and the name of the disease in the “Physician’s diagnosis” section.
In addition, in such case, describe all the prescribed drugs in the remarks section.
BMI =The person mentioned above is not infected with the infectious diseases shown above and there are no
health risks with regard to conducting stable and continuous employment activities in Japan.
(Physician) Signature参考様式第１－３号（別紙）Reference Form 1-3 (Attachment)

受診者の申告書
Declaration by Medical Checkup Examinee

私は，通院歴，入院歴，手術歴，投薬歴の全てを医師に申告した上で，医師の診断を受けました。
I hereby declare that I informed a doctor of my full medical
history, including hospital visits, hospitalization, surgeries, andmedication. After providing this information, I was examined by
the doctor.

作 成 年 月 日
年
Prepared on DD /MM /YYYY

申 請 人 の 署 名
Signature of the applicant

月日参考様式第１－５号
Reference Form 1-5

特

定

技

能

雇

用

契

約

書

EMPLOYMENT CONTRACT FOR SPECIFIED SKILLED WORKERS
Organization of affiliation of the specified skilled worker ______________________________________(hereinafter referred to as “organization”)
Specified skilled worker (including specified skilled worker candidates) __________________________(hereinafter referred to as “specified skilled worker”)
This Employment Contract is hereby entered into in accordance with the contents described in theattached Written Employment Conditions.
This Employment Contract shall come into effect upon the specified skilled worker entering Japan withthe status of residence of “Specified Skilled Worker (i)” or “Specified Skilled Worker (ii)”, and starting toengage in the activities for the work requiring the skills provided for in an ordinance of the Ministry ofJustice as stipulated by the Minister of Justice for a specified industrial field.
The period of the Employment Contract (beginning and end of the Employment Contract) stated in the
Written Employment Conditions must be changed in accordance with the actual date of entry if the dateof entry of the specified skilled worker differs from the scheduled date of entry.
The Employment Contract shall be terminated at the time of the period of the Employment Contract
expiring without being renewed, or if the specified skilled worker has forfeited the status of residence forany reason.
The Employment Contract and Written Employment Conditions shall be prepared in duplicate, and one
copy shall be retained by each party.
Entered into on DD/MM/YYYY

Organization
Seal(Name of the organization of affiliation of thespecified skilled worker, and name, title and seal of
its representative)

Specified skilled worker
Signature of the specified skilled worker)

参考様式第１－６号
Reference Form 1-6

雇

用

条

件

書

WRITTEN EMPLOYMENT CONDITIONS
DD/MM/YYYY
To:

Name of the organization of affiliation of the specified skilled worker:
Address: __________________________________________________________________________________
Tel. no.: ___________________________________________________________________________________
Representative’s name and title: _____________________________________________________________ Seal

I．Period of the employment contract
1. Period of the employment contract（From:(DD/MM/YYY) to(DD/MM/YYYY)

Scheduled date of entry:

DD/MM/YYYY）

2. Renewal of contract□ The contract shall be automatically renewed□ The contract may be renewed□ The contract is not renewable*If the contract may be renewed, the renewal of the contract shall be determined by the following criteria.
□ Volume of work to be done at the time the term of contract expires□ Employee’s work record and work attitude□ Employee’s capability to execute their tasks□ Business performance of the company□ State of progress of the work done by the employee□ Other ()

II．Place of employment□ Direct employment (fill in below)□ Dispatch employment (fill in the separate “Employment Conditions Statement”)

Name of office
Address
Contact information
III．Contents of work to be engaged in:
1. Field ()

2. Work category ()

IV．Working hours, etc.
１．Start and finish times(1) Start time: (:) Finish time: (:) (Number of prescribed working hours in one day: () hours () minutes(2) 【If the following systems apply to the worker】□ Irregular labor system： irregular labor system unit ()* If an irregular labor system is adopted, attach a copy of the yearly calendar in a language the specified skilled worker can fully understand, and acopy of the agreement on the irregular labor system submitted to the Labor Standards Inspection Office.

□ Work shift system using a combination of the following working hours
Start time ( :) Finishing time ( : ); Day applied (); prescribed working hours for one day () hours () minsStart time ( :) Finishing time ( : ); Day applied (); prescribed working hours for one day () hours () minsStart time ( :) Finishing time ( : ); Day applied (); prescribed working hours for one day () hours () mins

2. Break time(minutes)

3. No. of prescribed working hours ① Week () hours (4. No. of prescribed working days ① Week (□ Yes

5. Overtime work

) mins ② Month () days ② Month () mins ③ Year ( ) hours () hours () days ③ Year () mins) days□ No○ Details are stipulated in Article ( ), Article ( ) and Article ( ) of the Rules of Employment.

V．Days off
1. Regular days off: Every (), national holidays, others (2. Additional days off: () (total number of annual days off: () days per week/month, others () days)○ Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.
VI．Leave
Those working continuously for six months or more → (1. Annual paid leave) daysThose working continuously for up to six months（□ Yes □ No）→ After a lapse of ( ) months and (2. Other leave

Paid () Unpaid () days

)3. Leave for temporary return home: If the specified skilled worker wishes to return home temporarily, he or she must be given necessary days off
within the scope of the abovementioned 1 and 2.
○ Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.
VII．Wages
1. Basic pay□ Monthly wage (□ Daily wage (

yen)

yen)

□ Hourly wage (yen)* Details given in the attachment.
2. Various allowances (excluding additional pay rate for overtime)(allowance，

allowance，

allowance)* Details given in the attachment.
3. Additional pay rate for overtime, holiday work or night work
(1) Overtime work: Legal overtime 60 hours or less a month (Legal overtime over 60 hours a month() %Fixed overtime() %(2) Holiday work

Legal holiday work ((3) Night work(

□ () of every month; () of every month; (6.Method of wage payment) %，Non-legal holiday work (

) %

) %
□ (

4. Closing day of payroll
5. Pay day) %□ Bank transfer) of every month) of every month□ Payment in yen (cash)

7. Deduction from wages in accordance with labor-management agreement

□ No

□ Yes

* Details given in the attachment.
8. Wage raise□ Yes (Timing，amount, etc.

) □ No9. Bonus□ Yes (Timing amount, etc.

) □ No10．Retirement allowance□ Yes (Timing, amount, etc.

)

□ No

11. Leave allowance□ Yes (rate)

VIII．Items concerning retirement
1. Procedure for retirement for personal reasons (Notification should be made to the president or the factory foreman, etc. no less than () daysbefore retirement)
2. Reasons and procedure for the dismissal
In cases of dismissal, the specified skilled worker shall be dismissed through being given 30 days’ advance notice or at least 30 days of theaverage wage only when there are unavoidable reasons for the dismissal. In cases of dismissal based on a cause attributable to the fault of thespecified skilled worker, there is the possibility of immediate dismissal without giving advance notice or the average wage being paid on approvalbeing obtained from the Director of the Labor Standards Office Concerned.
Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.
IX．Others
１．Joining social insurance / employment insurance (□ Employees’ pension insurance，□ Health insurance，□ Employment insurance□ Industrial accident insurance □ National pension)□ National health insurance □ Others ()

２．Health check at the time of hiring: Month (３．First regular health check: Month () Year () Year ()) (every () afterwards)

４．If the specified skilled worker is unable to pay for the travel expenses to return to his or her home country after the termination of this contract, the organization shall pay for the travel expenses and take necessary measures to ensure smooth departure.

Recipient（signature）

参考様式１－６

別紙

Reference Form 1-6 Attachment

賃

金

の

支

払

PAYMENT OF WAGES
１．Basic Wages□

Monthly wage (yen) □yen) □ Hourly wage (Daily wage (* Amount per hour in cases of monthly or daily wages (yen)* Amount per month in cases of daily or hourly wages (

yen)

yen)

２．Amount and calculation method for various allowances (excluding the additional pay rate for overtime)(a) (allowanceyen; Calculation method

)

(b) (

allowanceyen; Calculation method

)

(c) (

allowanceyen; Calculation method

)

(d) (

allowanceyen; Calculation method)

３．Estimated payment per month (1+2)

approx.

４．Items to be deducted when paying wages(a) Tax(approx.

yen)(b) Social insurance(approx.

yen)(c) Employment insurance(approx.

yen)(d) Food(approx.

yen)(e) Housing (approx.

yen)(f) Others (utility costs)(approx.

yen)(approx.

yen)(approx.

yen)(approx.

yen)(approx.

yen)yen (total)

(approx.
Amount to be deducted

5．Take-home pay (3 - 4)yen)approx.

yen (total)

approx.

yen (total)* Provided there is no absence from work, etc. and excluding additional pay, etc. for overtime work.

参考様式第１－７号

Reference Form No. 1-7

事 前 ガ イ ダ ン ス の 確 認 書
CONFIRMATION OF ADVANCE GUIDANCE
1. Matters concerning the content of the work I am engaged in, the amount of remuneration, and otherworking conditions
2. Contents of the activities I am permitted to engage in while in Japan
3. Matters concerning the procedures for when I enter Japan
4. Neither I nor my spouse, lineal relative or relative cohabiting with me or any other person who has aclose relationship with me in terms of a social life are, in connection with the activities I am to engage
in while in Japan based on an employment contract for specified skilled workers, paying a deposit, or
having my money or other property otherwise being managed regardless of the reason therefor, and I
have not entered into a contract nor am I expected to enter into a contract that stipulates penalties withregard to non-performance of the employment contract for specified skilled workers or a contract
which otherwise expects the transfer of undue money or other property.
5. If I am paying expenses to an organization in my own country or another country in connection with anapplication for an employment contract for specified skilled workers, or for preparation for theactivities of specified skilled worker (i), I fully understand the amount and breakdown of the expenses,
and the organization must have entered into an agreement with me about these expenses.
6. I am not being made to pay directly or indirectly for the expenses required for my support.
7. The organization of affiliation of specified skilled workers, etc. must pick me up from the seaport or
airport at which I intend to enter Japan.
8. I am being given support pertaining to securing appropriate housing for me.
9. There is a system in place so I can make a request for advice or to make a complaint about my work
life, general living or social life.

From:
From:
From:

Time (
Time (
Time (:::) to () to () to (:::) on DD/MM/YYYY) on DD/MM/YYYY) on DD/MM/YYYYName of the organization of affiliation of specified skilled workers (or registered support
organization)

Name of the explaining party(Seal)

I have received an explanation from the above person and fully understood the contents.
In addition, with regard to 4, neither I, my spouse nor any related person has entered into a contract
concerning the payment of a deposit or penalties, nor will I enter into such contract in the future.

Signature of the specified skilled worker ________________________ DD/MM/YYYY参考様式第１－８号
Reference Form 1-8

支払費用の同意書及び明細書
CONSENT FOR PAYMENT OF EXPENSES AND WRITTEN STATEMENT OF EXPENSES
Specified skilled worker paying expenses
Name:
Sex:
Date of birth:

DD/MM/YYYY

Nationality / region:

Expenses collected by the organization in a foreign country
Name of organizationcollecting expenses

Expense item

Date of collection

1

DD/MM/YYYY

2

DD/MM/YYYY

3

DD/MM/YYYY

4

DD/MM/YYYY

5

DD/MM/YY'YYAmount

(

yen)

(

yen)

(

yen)

(

yen)

(

yen)

Total
(

yen)

Notes.
1. The organization in a foreign country is not restricted to any particular organization, and means an organization whichmediates applications for employment contracts for specified skilled workers or is involved in the preparations for theactivities.
2. Give the amount in the local currency or USD, and write the amount converted into Japanese yen in parentheses.
3. For the expense items, give the expense item as indicated to the applicant.

I paid the abovementioned amounts to the organization in a foreign country for the mediation of an
application for the employment contract for a specified skilled worker or the preparations for theactivities related to the status of residence of “Specified Skilled Worker” having fully understood thebreakdown of the expenses.
In addition, I have not paid any expenses other than the expenses listed above.
Prepared on DD/MM/YYYY
Signature of the specified skilled worker__________________________________

参考様式第１－１０号
Reference Form 1-10

技 能 移 転 に 係 る 申 告 書
WRITTEN DECLARATION ON THE TRANSFER OF SKILLS

Declarant
Name:
Sex:

Male / Female

Date of birth:
Nationality / region:

I hereby declare the following matters.
Details

I am aware that the purpose of the technical intern training program in Japan is to promoteinternational cooperation by transferring skills, etc. to developing regions etc.
I have acquired the skills, etc. pertaining to ________________ that would be difficult to acquire, etc.
in my home country of ___________________, and have completed the technical intern training.
Therefore, I would like to work on transferring the skills, technology or knowledge pertaining to____________________ which I acquired in Japan, or for which I increased or attained proficiency, tomy home country upon my return to my home country in future,
I hereby declare that the statement given above is true and correct.
Date:(DD/MM/YYYY)

Signature of the declarant ____________________

参考様式第１－１３号
Reference Form 1-13

就業条件明示書
Statement of Employment Conditions
年月日
DD/MM/YYYY

殿
To:
特定技能所属機関の氏名又は名称
Name of the organization of affiliation of
the specified skilled worker
住所
Address
電話番号
Telephone Number
代表者の氏名・役職
Name and title of the representative
派遣先の氏名又は名称
Name of client

印 Seal
印 Seal次の条件で労働者派遣を行います。
The employment conditions for worker dispatch are as follows.
業務内容
Job description
事業所名（部署名）
Name of the place of business (Name of department)
就業場所
Workplace

所在地
Address（電話番号(Telephone number

）
)

組織単位
Organizational unit
指揮命令者
Manager

職名
Title

氏名
Name
年

月

日から
年
月
from DD/MM/YYYY to DD/MM/YYYY

日まで（派遣先の事業所における期間制限に抵触する日）
年月日(The first day the work concerned will come into conflict with the restriction on the period per place of business of client)
DD/MM/YYYY

派遣期間
Period of worker
dispatch

就業日及び就業時間
Work days and hours（組織単位における期間制限に抵触する日）
年月日(The first day the work concerned will come into conflict with the restriction on the period per organizational unit)
DD/MM/YYYY

なお，派遣先の事業所における派遣可能期間の延長について，当該手続を適正に行っていない場合や派遣労働者個人
単位の期間制限を超えて労働者派遣の役務の提供を受けた場合は，派遣先は労働契約申込みみなし制度の対象となる。
However, if the applicable procedure for extending the period for which dispatch is possible at the client's place ofbusiness is not properly performed, or if the client receives the provision of worker dispatch services for a period thatexceeds the maximum period per dispatched worker, the client is deemed to have offered the subject worker an
employment contract.
就業日Work days
就業時間
時
分から
時
Work hours
from
:
to
:
（うち休憩時間時分から(Break time
from
:
to

分まで
時
:

分まで）
)

安全及び衛生Health & safety
時間/週
時間/月
時間）
時間外労働及び休日労 時間外労働（無/有）→（１日Overtime work (No/Yes) → (hours per day,hours per week, hours per month)働
Overtime work/work
休日労働 （無/有）→（１月回）
on holidays
Work on holidays (No/Yes) → (times per month)
派遣元責任者
Responsible person
職名
acting for the dispatch Title
business operator

氏名
Name

（電話番号
(Telephone number）)

派遣先責任者
Responsible person
acting for the client

氏名
Name

（電話番号
(Telephone number

）
)

職名
Title

福利厚生施設の利用等
Use of welfare
facilities, etc.

- 1 -

苦情の処理・申出先
Persons in charge ofhandling complaints
submitted by thedispatched worker

申出先

派遣元：

Contact information Dispatch business operator:

職名
Title

派遣先：
Client:

職名
Title

氏名
Name

（電話番号
(Telephone number

)

）

氏名
Name

（電話番号
(Telephone number)）

派遣契約解除の場合の措置
Measures forterminating the worker
dispatch contract
派遣先が派遣労働者を雇用する場合の紛争防止措置
Measures forpreventing disputes
where the client
employs thedispatched worker
備 考
Remarks

就業条件明示書記載要領
How to fill out the employment conditions statement

1 各欄において複数項目の一を選択する場合には該当項目に○印を付すこと。
If there is more than one item to choose from in each section, circle the applicable one.

2 「業務内容」欄には、派遣先において従事する業務の内容、その業務に必要とされる能力等を具体的に記載すること。
Specifically describe the details of work to be performed at the client's place of business, and skills required for the work, in the "Job description"section.

3 「就業の場所」欄には、主な就業場所を記載するものとし、それ以外に出張等により就業の場所が異なることがある場合には、備考欄に記載すること。
The main workplace must be stated in the "Workplace" section, and if there is another workplace where the dispatched worker may go to on abusiness trip, etc., that workplace must be stated in the "Remarks" section.

4「組織単位」欄には、課、グループ等の業務としての類似性や関連性がある組織であり、かつ、その組織の長が業務の配分や労務管理上の指揮監
督権限を有している組織を記載すること。
Regarding the "Organizational unit" section, fill in the organization (division, group, etc.) that is most similar and relevant to the work to be performedby the dispatched worker. Also, the head of that organization must have the right to direct and supervise the work allocation and labor management.

5 派遣労働者が労働者派遣に係る労働に従事する事業所等の業務について、派遣先が派遣可能期間の制限に抵触することとなる最初の日を「派遣期間」欄のに記載すること。（派遣先の事業所単位の期間制限の抵触日）
The first day the work concerning the work to be performed by the dispatched worker under worker dispatch arrangements at the place of businesswill come into conflict with the restriction on the period for which dispatch is possible per place of business of the client shall be stated inin the section of "Period of worker dispatch."(The first day the work concerned will come into conflict with the restriction on the period per place of business of the client)

また、派遣労働者が労働者派遣に係る労働に従事する事業所その他派遣就業の場所における組織単位の業務について派遣元事業主が期間の制限に抵触することとなる最初の日を組織単位欄の内に記載すること。（個人単位の期間制限の抵触日）
なお、組織単位における期間制限の抵触日は延長されることはないこと。
However, regarding the work per organizational unit to be performed by the dispatched worker under the worker dispatch arrangements at the placeof business or other workplace of dispatch work, the first day on which the dispatch business operator will come into conflict with the restriction on the
period must be stated inin the "Organizational unit" section.
(The first day the work concerned will come into conflict with the restriction on the period per dispatched worker)
Also, the first day the work concerned will come into conflict with the restriction on the period per organizational unit must not be extended.

6 「就業日」は、具体的な曜日又は日を記載すること。
Fill in the specific day of the week or date in the "Work days" section.

7 「安全及び衛生」欄には、次の事項のうち、派遣労働者が派遣先において業務を遂行するに当たって、当該派遣労働者の安全、衛生を確保するために必要な事項に関し、就業条件を記載すること。
In the "Health & safety" section, fill in the employment conditions regarding the matters (from those items shown below) necessary for ensuring thehealth and safety of the applicable dispatched worker to perform his/her duties at the client's place of business.
・

危険又は健康障害を防止するための措置に関する事項（例えば、危険有害業務に従事させる場合には、当該危険有害業務の内容、当該業務による危険又は健康障害を防止する措置の内容等）
Matters concerning measures to prevent danger or health impairment (e.g. if the dispatched worker will be engaging in dangerous work, fill in thedetails of such dangerous work and the measures to prevent danger or health impairment caused by such work, etc.)

・

健康診断の実施等健康管理に関する事項（例えば、有害業務従事者に対する特別な健康診断が必要な業務に就かせる場合には、当該健康診断の実施に関する事項等）
Matters concerning health management, such as conducting medical check-ups, etc. (e.g. if the dispatched worker will be engaging in work that
requires a special medical check-up for those in charge of dangerous work, fill in details about performing those medical check-ups, etc.)

・換気、採光、照明等作業環境管理に関する事項
Matters concerning management of the work environment, such as ventilation, lighting, and illumination, etc.

・安全衛生教育に関する事項（例えば、派遣元及び派遣先で実施する安全衛生教育の内容等）
Matters concerning health and safety education (e.g. details of the health and safety education provided by the dispatch business operator, andthe client, etc.)- 2 -参考様式第１－１３号
Reference Form 1-13
・
・

・
・

免許の取得、技能講習の終了の有無等就業制限に関する事項（例えば、就業制限業務を行わせる場合には、当該業務を行うための免許や技能講習の種類等）
Matters concerning restrictions on employment, such as license acquisition, completion of a skill training course, etc. (e.g. if the dispatched worker isto engage in work that imposes restrictions on employment, fill in the types of license and skill training course that will enable the dispatched worker
to perform the work, etc.)
安全衛生管理体制に関する事項
Matters concerning the health and safety management system
その他派遣労働者の安全及び衛生を確保するために必要な事項
Other matters necessary for ensuring the health and safety of the dispatched worker

8 「時間外・休日労働」については、６の派遣就業をする日以外の日に派遣就業をさせることができ、又は派遣就業の開始の時刻から終了の時刻までの時間を延長することができる旨の定めを労働 者派遣契約において行った場合には、当該派遣就業をさせることができる日又延長することができる時間数を記載すること。
Regarding the "Overtime work/work on holidays" section, if the provision that enables the dispatch business operator to have the dispatched worker
work on a day other than work days mentioned in paragraph 6 above, or extend the work hours (from the start time to the finish time of the dispatchwork) is stipulated in the worker dispatch contract, fill in the available day(s) for such dispatch work, or the extendable hours.
なお、労働者派遣契約においてこの定めをする場合には、当該定めの内容が派遣元事業主と派遣労働者との間の労働契約又は派遣元事業場における36協定により定められている内容の範囲内であることが必要である。
However, for this provision in the worker dispatch contract to take effect, the contents of such provision must be within the scope of the contents ofthe provisions of the labor contract between the dispatch business operator and the dispatched worker, or 36 agreement at the dispatch business
operator's place of business.

9 「派遣先責任者」は、派遣先責任者の選任を要しない場合であっても、派遣先責任者が選任されている場合には記載すること。

Even in cases that do not require an appointment with the responsible person acting for the client, if such person is appointed, fill in his/her name inthe "Responsible person acting for the client" section.

10 「福利厚生施設の利用等」欄には、派遣先が派遣労働者に対し、診療所、給食施設等の施設であって現に派遣先に雇用される労働者が通常利用しているものの利用、レクリエーション等に関する施設又は設備の利用、制服の貸与その他の派遣労働者の福祉の増進のための便宜を提供する旨の定めを労働者派遣契約において行った場合には、その定めを記載すること。
If the provision where the dispatch business operator allows the dispatched worker to use facilities such as the infirmary, food service facilities, etc.,
which are in fact normally used by the regular employees of the client concerned, use recreational facilities or equipment, use the uniform lending
service, and receive other benefits to promote the welfare of the dispatched worker, is stipulated in the worker dispatch contract, fill in the provision in
the "Use of welfare facilities, etc." section.

11 「苦情の処理・申出先」欄には、派遣労働者から苦情の申出を受けた場合の苦情の処理について、労働者派遣契約に定めた苦情の申出先、苦情の処理方法、派遣元事業主と派遣先の連絡体制等を具体的に記載すること。
Regarding the handling of complaints that have been submitted by the dispatched worker, enter in detail the contact information, how to handle
complaints, and the communication network between the dispatch business operator and the client, which are specified in the worker dispatch
contract, etc., in the "Persons in charge of handling complaints submitted by the dispatched worker" section.

12 「派遣契約解除の場合の措置」欄には、派遣労働者の責に帰すべき事由以外の事由による労働者派遣契約の解除が行われた場合には派遣先と連携して新たな就業機会の確保を図ること、労働者派遣契約の解除に伴う解雇を行った場合には労働基準法等に基づく責任を果たすこと等，派遣労働者の雇用の安定を図るための措置を具体的に記載すること。
In the section of "Measures for terminating the worker dispatch contract," enter in detail the measures to contribute to stable employment of
dispatched workers (e.g. in the case of terminating a worker dispatch contract for reasons not attributable to the dispatched worker, strive to secure
new job opportunities in cooperation with the client, and in the case of dismissal by terminating a worker dispatch contract, fulfill the responsibilities
stipulated in the Labor Standards Act and related laws, etc.).

13 「派遣先が派遣労働者を雇用する場合の紛争防止措置」欄には労働者派遣の役務の提供を受ける者が、労働者派遣の終了後に、当該労働者派遣に係る派遣労働者を雇用する場合に、その雇用意思を事前に労働者派遣をする者に対し示すこと、当該者が職業紹介を行うことが可能な場合は職業紹介により紹介手数料を支払うことその他の労働者派遣の終了後に労働者派遣契約の当事者間の紛争を防止するために講ずる措置を記載すること。
In the "Measures for preventing disputes where the client employs the dispatched worker" section, describe the following measures. In the case where theservice recipient of worker dispatching employs the dispatched worker pertaining to the said worker dispatching after the termination of worker
dispatching:(i) The service recipient must show the dispatch business operator its intention to employ the dispatched worker in advance.
(ii) If such dispatch business operator can provide the employment placement service, that service recipient shall pay the placement fee for theemployment placement service.
(iii) Other measures to be taken to prevent disputes among parties concerned in the worker dispatch contract after termination of worker dispatch.

14 「備考」欄"Remarks" section①(1)

政令第４条第1項各号で定める業務について労働者派遣を行う場合は、政令の号番号を記載すること。
If worker dispatch is carried out for work prescribed by each item of Article 4 (1) of the Cabinet Order, the item number of the Cabinet Order shall be
stated.
ただし、日雇労働者に係る労働者派遣が行われないことが明らかである場合は、この限りではない。
However, this shall not apply to the case where it is clear that worker dispatch does not pertain to day laborers.
・ 「日雇労働者に係る労働者派遣が行われないことが明らかである場合」とは、"The case where it is clear that worker dispatch does not pertain to day laborers" shall mean any of the following,(i) 無期雇用労働者(a)の労働者派遣に限る場合
Worker dispatch is limited to dispatched workers with indefinite-term contracts (a).
(ⅱ) 契約期間が31日以上の有期雇用労働者(b)の労働者派遣に限る場合
Worker dispatch is limited to dispatched workers with fixed-term contracts whose term is 31 days or more (b).
(ⅲ) (a)又は(b)の労働者派遣に限る場合
Worker dispatch is limited to the aforementioned dispatched workers (a) or (b).のいずれかであり、かつその旨を「備考」欄に記載すること。
and must be stated in the "Remarks" section.

②(2)

派遣可能期間の制限を受けない業務に係る労働者派遣を行う場合は、それぞれ必要事項を「備考」欄に記載すること。
If worker dispatch is carried out for work that is not subject to the restriction on the period for which dispatch is permitted, enter the necessary details
in the "Remarks" section.
・事業の開始、転換、拡大、縮小又は廃止のための業務について労働者派遣を行う場合は、その旨を記載すること。
If the worker is dispatched to engage in work to start, change, expand, downsize, or close down the business, this fact must be stated.

- 3 -

・

・

・
・

その業務が１か月間に行われる日数が当該派遣就業に係る派遣先に雇用される通常の労働者の１か月間の定労働日数に比し相当程度少なく
かつ月10日以下である業務について労働者派遣を行う場合は、(i)その旨、(ii)当該派遣先においてその業務が１か月間に行われる日数、(iii)当該派遣先の通常の労働者の１か月間の所定労働日数を記載すること
In the case of worker dispatching for work where the number of days on which that work is performed in a period of one month isconsiderably less than the normal prescribed number of working days per month for the regular employees employed by the client for that
dispatch work, and is 10 days or less, fill in the following details.
(i) The details of the work undertaken(ii) The number of days on which that work is performed in a period of one month at that client(iii) The normal prescribed number of working days per month for regular employees employed by that client
産前産後休業、育児休業等の代替要員としての業務について労働者派遣を行う場合は、派遣先において休業する労働者の氏名及び業務並びに当該休業の開始及び終了予定の日を記載すること。
If dispatching the worker to fulfill the duties of an employee taking maternity leave before and after childbirth, child-care leave, etc., fill in
the name and work duties of the employee who is taking such leave and is employed by the client, and the scheduled start and end date ofsuch leave.

・

介護休業等の代替要員としての業務について労働者派遣を行う場合は、派遣先において休業する労働者の氏名及び業務並びに当該休業の開始
及び終了予定の日を記載すること・ If dispatching the worker to fulfill the duties of an employee taking family care leave, etc., fill in the name and work duties of the employee
who is taking such leave and is employed by the client, and the scheduled start and end date of such leave.
③ 紹介予定派遣に係る労働者派遣である場合には、(i)紹介予定派遣である旨、(ii)紹介予定派遣を得て派遣先が雇用する場合に予定される雇用契約の(3) 期間の定めの有無等の労働者派遣契約において定めた紹介予定派遣に関する事項、(iii)紹介予定派遣を受けた派遣先が、職業紹介を受けることを希望しなかった場合又は職業紹介を受ける者を雇用しなかった場合には、それぞれのその理由を、派遣労働者の求めに応じ、書面、ファクシミリ
又は電子メール（ファクシミリ又は電子メールによる場合にあっては、当該派遣労働者が希望した場合に限る。）により、派遣労働者に対して明示する旨、(iv)紹介予定派遣を経て派遣先が雇用する場合に、年次有給休暇及び退職金の取扱いについて、労働者派遣の期間を勤務期間に含めて算入する場合はその旨を「備考」欄に記載すること。
In the case of the worker dispatching pertaining to the employment placement dispatching, fill in the following matters in the "Remarks" section. (i) It
is dispatch for employment placement. (ii) Matters concerning employment placement dispatch specified in the worker dispatch contract (e.g. If theclient employs the dispatched worker through employment placement dispatch, etc., whether the scheduled employment contract is a fixed-term
contract or not) (iii) If the client using the employment placement dispatch service did not wish to accept the employment placement service or did
not employ the dispatched worker who had been introduced to the client through the employment placement service, the reason for doing so must
be clearly indicated to the dispatched worker, at his/her request, by way of delivering a document, transmission by facsimile or e-mail (transmission
by facsimile or e-mail shall be limited to the case where the said dispatched worker preferred such method).
(iv) In the case where the client employs the dispatched worker via employment placement dispatch, if the period of worker dispatch is included in
the calculation of years of service to determine the handling of annual paid leave and retirement allowance, this must be stated.
④(4)

労働者派遣に関する料金の額を記載する場合は、次のいずれかを日額、月額等わかるようにした上で「備考」欄に記載すること。
When filling in the price for dispatching a worker, enter any of the following in the "Remarks" section, clearly stating the unit of the amount (e.g.
amount per day or per month, etc.).
・・

当該労働者に係る労働者派遣に関する料金の額
The price of dispatching the said dispatched worker

・・

当該労働者に係る労働者派遣を行う事業所における労働者派遣に関する料金の額の平均額
The average price for worker dispatch at the dispatch business operator's place of business for work performed by the said dispatchedworker⑤ 該当する各法令に基づき、健康保険被保険者資格取得届、厚生年金保険被保険者資格取得届、雇用保険被保険者資格取得届の書類が行政機関に提(5) 出されていない場合は、その理由を記載すること。
If the documents for written notice of acquiring health insurance qualification, written notice of acquiring welfare pension insurance qualification, andwritten notice of acquiring employment insurance qualification are not submitted to administrative bodies in accordance with the applicablerespective laws and regulations, please state the reason.

15 個々の派遣労働者に明示される就業条件は、労働者派遣契約の定めた就業条件の範囲内でなければならないこと。

The employment conditions clearly indicated to the respective dispatched workers must be within the scope of the employment conditions specified
by the worker dispatch contract.

- 2 -参考様式第１－１６号
Reference Form 1-16

雇 用 の 経 緯 に 係 る 説 明 書
Explanation of Employment Background
特定技能外国人との間で特定技能雇用契約を締結するに当たっての雇用の経緯は以下のとおりです。
Regarding the conclusion of the employment contract with specified skilled worker _________________, theemployment background is as follows.
１ 職業紹介事業者（国内）
Employment placement business provider (in Japan)
１ あっせんの有無
Use of an employment
placement service i□

２ 許可・届出受理番号（受理受付年月日）
Acceptance No. forapproval and notification(Date of acceptance andreceipt)
３ 職業紹介事業者の区分
Category of theemployment placementbusiness provider

□ 無

有
Yes

No

－ －
－ －

（
（

年
DD

月
/MM

/YYYY

日）
）

□ 有料職業紹介事業者□ Fee-charging employment placement business provider□ 無料職業紹介事業者□ Free employment placement business provider

４ 職業紹介事業者の氏名
Name of the employment
placement businessprovider５ 職業紹介事業者の住所（電話番号）
Address of theemployment placementbusiness provider(Telephone number)

６ 職業紹介事業者へ支払った
費用
Expenses paid to theemployment placementbusiness provider

〒

－
（電話番号
（Telephone number

求職者
（申請人）
Job seeker(the applicant)
求人者（特定技能所属機関）
Job offeror(the organization ofaffiliation of thespecified skilledworker)額
Amount

－
－

（
（

名目
Description For payment of額Amount名目
Description For payment of

－
－

）
）

円）
yen）
として

（
（

円）
yen）
として

（注意）
(Notes)
１ １欄で無にチェックを付した場合には，２以下の欄の記載は不要とする。
If you ticked “No” in section 1, you do not need to fill out sections below section 2.
２ ２から５欄までは，厚生労働省職業安定局ホームページの「人材サービス総合サイト」を活用し，当該職業紹介事業者についての該当する情報を記入すること。
Fill in the relevant information for the applicable employment placement business provider in sections 2, 3, 4, and 5, using the“Comprehensive Human Resource Services Website” which is operated by the Employment Security Bureau of the Ministry of Health, Labourand Welfare.
３ ６欄は，求職者及び求人者が職業紹介事業者に支払った額及び名目について記載すること。なお，求職者が日本円以外で費用を支払った場
合は，当該通貨で支払った額及び日本円に換算した額を記載すること。
Fill in the amount and description of the money paid by the job seeker and job offeror to the employment placement business provider insection 6. Please note that if the job seeker paid the expense in a currency other than yen, you must state the amount paid in the local
currency, as well as that amount converted to yen.
４ 職業紹介事業者との間で交わした契約書があれば，その写しを添付すること。
If you have a written contract exchanged with the employment placement business provider, please attach a copy of it.

２ 取次機関（国外）（１で有にチェックを付した場合のみ記載）
Agent organization (outside Japan) (Only those who ticked “Yes” in section 1 above need to fill in the form
below)
１ 取次ぎの有無
Use of service provided by
the agent organization
２ 氏名又は名称
Name of the agent
organization
３ 所在国Country where the agent
organization is located

□ 有
Yes

４ 所在地
Address of the agent
organization

No

（電話番号
（Telephone number

求職者
（申請人）
Job seeker(the applicant)
５ 取次機関へ支払った費用
Expenses paid to the agent
organization

□ 無

求人者
（特定技能所属機関）
Job offeror(the organization ofaffiliation of thespecified skilledworker)額
Amount名目
Description
額Amount名目
Description

－
－
（
（

－
－

）
）
円）
yen）
として

For payment of
（
（

円）
yen）
として

For payment of（注意）(Notes)１ 取次機関とは，職業紹介事業者が求人者に求職者のあっせんを行うに際し，当該職業紹介事業主に対し求職者等に係る情報の取次ぎを行う者をいう。
The agent organization means the party that acts as the agent handling the job seeker’s information for the applicable employment
placement business provider, in the case where the job offeror uses the employment placement service provided by the employment
placement business provider to recruit the job seeker.
２ １欄で無にチェックを付した場合には，２以下の欄の記載は不要とする。
If you ticked “No” in section 1, you do not need to fill out sections below section 2.
３ ５欄は，求職者及び求人者が取次機関に支払った額及び名目について記載すること。なお，求職者及び求人者が日本円以外で費用を支払った場合は，当該通貨で支払った額及び日本円に換算した額を記載すること。
Fill in the amount and description of the money paid by the job seeker and job offeror to the agency organization in section 5. Please note that
if the job seeker and job offeror paid their expenses in a currency other than yen, you must state the amount paid in the local currency, as wellas that amount converted to yen.

４ 取次機関との間で交わした契約書があれば，その写しを添付すること。
If you have a written contract exchanged with the agency organization, please attach a copy of it.

以上の内容について相違ありません。
I hereby declare that the statement given above is true and correct.

作成年月日：

年

月

Prepared on DD /MM /YYYY

特定技能所属機関の氏名又は名称
Name of the organization ofaffiliation of the specified skilled worker
作成責任者の氏名及び役職
Name and title of the person
responsible for preparing this document
申

請

人

の

署

Signature of the applicant

名

㊞
Seal

日

参考様式第１－１７号
Reference Form 1-17

１ 号 特 定 技 能 外 国 人 支 援 計 画 書
Support Plan for Specified Skilled Worker (i)Prepared:

Ⅰ Subject of support

1. Name2. Sex(No of other potential specified skilled workers:

3. Date of birth

DD

MM

YYYY

MM

DD

YYYY

Male/ Female)
4. Nationality / Region

Ⅱ Organization of affiliation of specified skilled workers (i)1. Name with furigana
Postal code－

2. Address（Telephone no.
3. Corporate number

4. Details of the structure inplace to perform the support
work

Support manager

Name with
furigana

No. of specified skilled workers(i) providing support

No. of persons:No. of support staff

No. of persons:

Title

－

－

）

1. Registration number

2. Date ofregistration

Registration －DD/MM/YYYY

3. Scheduled date of startof support work

DD/MM/YYYY

4. Name with furigana
Postal code－

5. Address

In the case of acorporation

Ⅲ Registered support organization（Telephone number

－

－

）

（Telephone number

－

－

）

6. Name of therepresentative with
furigana
7. Corporate number
Postal code－

8. Address of the officeproviding support

9. Details of the structure inplace to perform the support
work

Support manager

Name with
furigana

No. of specified skilled workers(i) providing support

No. of persons:No. of support staff

No. of persons:

Title

Contents of support
a. Matters concerning the content ofwork to be engaged in, the amount of
remuneration, and other working
conditions
b. Contents of activities that can be
engaged in while in Japan

Scheduled implementationof support□ Yes（

）

□ No（

）

□ Yes（

）

□ No（

）

□ Yes（

）

□ No（

）

d. Prohibition of the collection of adeposit or conclusion of a contract
which stipulates penalties with regard
to non-performance of the contracte. If expenses are to be paid to anorganization in a foreign country in
relation to preparations for entry into
Japan, the specified skilled worker (i)must fully understand the amount of
the expenses and a breakdown before
paying the expenses□ Yes（

）

□ No（

）

□ Yes（

）

□ No（

）

f. The foreign national must not bemade to pay any expenses necessary
for the support□ Yes（）

c. Matters concerning procedures forentering Japan

Support staff or implementing staff if the support is to be outsourced
Name(Title)Address(Only when outsourced)
Postal code－

Yes / No
Postal code－

Postal code－

Postal code－

Yes / NoYes / No

1. Provision of advance guidance

Ⅳ Contents of support

A. Contents of information provision, etc.

Yes / No
Postal code

□ No（

）

g. Contents of support relating to□ Yes（picking the specified skilled worker (i)□ No（
up at the time of entry into Japan）□ Yes（

）

□ No（

）

h. Contents of support relating tosecuring housing

Outsourced
Yes Noi. Contents relating to handling of□ Yes（consultations for advice and□ No（complaints
j. Name and contact information of the□ Yes（support staff of the organization ofaffiliation of the specified skilled□ No（
worker (i)Free description□ Yes(Other details)
□ No

）

）

Postal code－

Postal code－

Postal code－

Postal code－

Postal code－

Yes / NoYes / NoYes / No）Yes / No

Postal code
Yes / No□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（Yes / No）□ In person□ Video call equipment□ Other（

）

）

）

）

－

Yes / No）

Implementation method(Check all the applicable boxes)－□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（□ In person□ Video call equipment□ Other（

）

）

）

）

）

）

）

B. Language that the support is to be given in Language:
C. Scheduled hours of support

2. Pick up and drop off at time ofentry or departure

Contents of support

Total number of hours:

Scheduled implementation

a. Pick up at the airport or seaport of arrival□ Yes（and transfer to the organization of affiliationof the specified skilled worker (i) or to the□ No（
accommodationb. Drop off at the scheduled airport or seaport□ Yes（of departure and assistance with the departure
procedures until entering the security check □ No（
line
Free description□ Yes(Other details)□ No

A. Support related to securing suitable accommodation

3. Support for suitable accommodation and contracts for general living

Contents of support

c. With the agreement of the specificskilled worker (i) provide company
housing, etc. as a residence

Support staff or implementing staff if the support is to be outsourced
Name(Title)）））Address(Only when outsourced)
Postal code－

Yes / No）

Postal code－

Postal code－

Yes / No

Implementation method(Check all the applicable boxes)□ Airport or seaport of arrival(
Airport)）□ Method of pick-up（□ Scheduled airport or seaport of departure(
Airport/Undecided)）□ Method of pick-up（

Yes / No

Scheduled implementationof support

a. Provision on information on realestate agencies and rental properties,
and where necessary, accompanying
the specified skilled worker (i) to help
with the procedures to secure housing,and assist in finding a residence. In
addition, if a guarantor is required at □ Yes（
the time of the conclusion of the rental□ No（
contract, and there is no suitableguarantor, either become a guarantor
for the specified skilled worker (i) or
secure an available rental debt
guarantor who will act as the guarantorof the specified skilled workers (i), andact as the emergency contact
b. Personally become the tenant andenter into a rental agreement, and offer □ Yes（
the residence to the specified skilled□ No（
worker (i) with his/her consent

Outsourced
Yes NoOutsourced
Yes NoSupport staff or implementing staff if the support is to be outsourced
Name(Title)Address(Only when outsourced)
Postal code－））

Yes / No））

□ Yes（

）

□ No（

）

Postal code－

Postal code－

Yes / NoYes / No

Method of implementation of support

Free description(Other details)

Postal code

□ Yes
□ No
□

－

Yes / No

Whether housing has already been secured at the time of submission of the application for permission to change the status of residence (or application of issuanceof a certificate of eligibility)

Whether housing is to be secured after submission of the application for permission to change the status of residence (or application of issuance of a certificate ofd. Summary of the residence for which □
eligibility)
information is to be provided or theSize of room
(Total no. of co-habitants:)
housing to be provided as residence(including cases where planned for□ At least 7.5 ㎡ per person
provision)□ Less than 7.5 ㎡ per person□ At least 4.5㎡ per person□ Less than 4.5㎡ per person

Contents of support

Scheduled implementation

B. Support related to contracts necessary for general living

a. Assist with procedures to open a□ Yes（deposit account or savings account at abank or other financial institution
□ No（

）

Outsourced
Yes NoSupport staff or implementing staff if the support is to be outsourced
Name(Title)□ Provision of information on procedures－□ Where necessary, accompany the
specified skilled worker (i) to assist withthe procedures)□ Others (□ Provision of information on procedures－□ Where necessary, accompany the
specified skilled worker (i) to assist withthe procedures)□ Others (□ Provision of information on procedures

Yes / No）
Postal codeb. Assist with procedures to enter into □ Yes（a contract for use of a mobile phone
□ No（

）

Yes / No）
Postal codec. Assist with procedures for lifelines
such as electricity, water, gas□ Yes（

）

□ No（

）

Free description(Other details)□ Yes

Postal code

Scheduled implementation

a. Matters concerning general living in □ Yes（
Japan
□ No（

□ Where necessary, accompany the
specified skilled worker (i) to assist withthe procedures)□ Others (Yes / No－Yes / No

□ No
Contents of support

Implementation method(Check all the applicable boxes)

Address(Only when outsourced)
Postal code－

Outsourced
Yes No））Yes / No

Support staff or implementing staff if the support is to be outsourced
Name(Title)Address(Only when outsourced)
Postal code－

Implementation method(Check all the applicable boxes)□ Oral□ Written (including a translation))□ Others (A. Contents of information provision

4. Implementation of guidance on general living

b. Matters concerning notification toan organization of the national
government or local government which
the specified skilled worker (i) has to□ Yes（make pursuant to the provisions oflaws and regulations and mattersNo（
relating to other procedures, and where □necessary, accompanying the specified
skilled worker (i) to assist with theproceduresc. Contact information for
consultations and complaints, contact
information of the organization of thenational or local government where arequest is to be filed

Postal code

）

）

□ No（

）

e. Matters related to disasterprevention and crime prevention, and □ Yes（
other necessary matters for responses
at the time of a sudden illness or other □ No（
emergencies
f. Method of response on becoming
aware of a violation of laws andregulations relating to immigration or □ Yes（
labor, and other matters necessary forNo（legal protection of the specified skilled □worker (i)Free description□ Yes(Other details)□ No

Yes / No

Postal code－

□ Oral□ Written (including a translation))□ Others (Postal code－

□ Oral□ Written (including a translation))□ Others (Postal code－

□ Oral□ Written (including a translation))□ Others (Postal code－

Postal code－

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

B. Language that the support is to be given in Language:
C. Scheduled hours of support□ Oral□ Written (including a translation)□ Where necessary, accompany the
specified skilled worker (i) to assist withthe procedures)□ Others (）□ Yes（d. Matters concerning medical
institutions where the specified skilled □ Yes（
worker (i) will be able to receive□ No（
medical treatment in a language thathe/she is fully able to understand－Total number of hours:

Yes / No□ Oral□ Written (including a translation))□ Others (□ Oral□ Written (including a translation))□ Others (5. Provision of opportunities for Japanese language studies

Scheduled implementation

Contents of the support

a. Provision of information on admission
guidance for Japanese language classes and □ Yes（Japanese language institutions, and□ No（
accompanying as needed to assist withadmission proceduresb. Provision of information on Japanese
language learning materials for self-learning□ Yes（and online Japanese language courses, andwhere necessary, obtaining Japanese□ No（language learning materials and assisting withthe contract procedures for using online
Japanese language courses
c. Based on an agreement with the specified
skilled worker (i), enter into a contract with a □ Yes（Japanese language instructor and provide□ No（
opportunities for the specified skilled worker(i) to study JapaneseFree description□ Yes(Other details)□ No

A. Contents of responses, etc.

6. Responses to consultations or complaints

Contents of the support

Free description(Other details)

Support staff or implementing staff if the support is to be outsourced
Name(Title)））Address(Only when outsourced)
Postal code－）

Yes / No

Postal code－

Postal code－

Postal code－

Yes / No））

Scheduled implementation

Yes (implemented in atimely manner)）□ No（

Yes / NoYes / No

Outsourced
Yes NoSupport staff or implementing staff if the support is to be outsourced
Name(Title)Address(Only when outsourced)
Postal code－

Postal code－

Postal code－

Yes / No□Yes / No

□ Yes
□ No

Implementation method(Check all the applicable boxes)）

a. Appropriate responses to a request
Yes (implemented in a
for a consultation or to a complaint in a□timely manner)
language that can be fully understood
without delay, and giving of necessary □ No（）
advice and guidanceb. Where necessary, give informationon the relevant administrative
organization corresponding to thecontent of the consultation, and assist
with necessary procedures such asaccompanying the specified skilledworker (i)Outsourced
Yes NoYes / No

Mon

Tues

Wed

Thurs

Fri

From : to :From : to :From : to :From : to :From : to :Weekdays
Response times

From : to :Sun

From : to :Holidays

From : to :Method of consultation

Implemented through the following method (check all the applicable boxes)

Emergency responses

B. Implementation method

Sat

Implemented through the following method at times of emergency (check all the applicable boxes)□ Direct interview□ Telephone（

－

－

）

□ Email（）□ Others（）□ Direct interview□ Telephone（

－

－

）

□ Email（）□ Others（）

C. Language of consultation
7. Support for promotion of exchanges with Japanesenationals

Contents of the support

Language:

Scheduled implementationa. Where necessary, provision of information
on places of interaction with local residents
hosted by local governments and volunteer□ Yes（groups, and on local community meetings,
and accompanying the specified skilled□ No（
worker (i), where necessary, to assist with
explaining precautions and implementation
methods of each eventb. As information necessary to understandJapanese culture, provision of information on□ Yes（local events related to working or living inJapan, and accompanying the specified□ No（
skilled worker (i), where necessary, to assist
with explanations onsite

Outsourced
Yes NoSupport staff or implementing staff if the support is to be outsourced
Name(Title)Address(Only when outsourced)
Postal code－））

Yes / No

Postal code））

Yes / No－

Implementation method

Free description(Other details)

Postal code

□ Yes
□ No

Contents of the support

8. Support for a job change except where caused by the foreign national

a. Obtaining and providing information on
the next accepting organization through an
industry association or affiliated company,
etc.
b. Provision of information on public
employment agencies and other employment
agencies and accompanying the specified
skilled worker (i) to assist as needed withfinding the next accepting organization

Scheduled implementation□ Yes（

）

□ No（

）

□ Yes（

）

□ No（

）

c. Preparing a letter of recommendation to
enable the specified skilled worker (i) toreceive employment advice or workplace
introductions or to be able to engage in job- □ Yes（
hunting activities based on the desired□ No（
conditions, skills level, and Japanese
language skills of the specified skilled worker(i)d. Mediation to find a place of employment in□ Yes（cases where it is permitted to mediate for
employment having received permission or□ No（
notification for a work intermediating
business
e. Granting of paid leave necessary for the□ Yes（specified skilled worker (i) to engage in job□ No（
hunting activities
f. Provision of information on necessary
administrative procedures when leaving theworkplace□ Yes（□ No（

g. When it is expected that support for a jobchange cannot be properly implemented due □ Yes（
to bankruptcy or some other reason, securing□ No（
of a person who will be able to provide
support in lieu of the organization
Free description(Other details)

Outsourced
Yes NoSupport staff or implementing staff if the support is to be outsourced
Name(Title)Address(Only when outsourced)
Postal code－

Implementation method(Check all the applicable boxes)

Yes / No
Postal code－

Postal code－

Postal code－

Postal code－

Postal code－

Postal code－

Yes / No））Yes / No））Yes / No））））Yes / No））Yes / No

□ Yes
□ No

－

Yes / NoYes / No□ Oral□ Written□ Others ()

Contents of the support

Scheduled implementation

A. Contents of interviews, etc.

9. Conducting of periodic interviews and notification to administrative agencies

a. Conducting of periodic interviews
with the specified skilled worker (i)□ Yes（and those who are in charge ofsupervising him/her in order to confirm □ No（
the work and living conditions of thespecified skilled worker (i)b. Provision of the information
provided in the general living
orientation in order to go over the
information again□ Yes（□ No（

c. Notification to the Labor Standards
Inspection Office or other relevant□ Yes（administrative agencies on becoming
aware of a violation of the Labor□ No（
Standards Act or other labor-related
laws
d. Notification to the Regional
Immigration Services Bureau on
becoming aware of a violation of the
Immigration Control Act such as the□ Yes（specified skilled worker (i) engaging in
activities other than those authorized □ No（
under the status of residence, or otherproblems such as confiscation of thepassport or residence card
Free description(Other details)

Outsourced
Yes No）At least once every (Address(Only when outsourced)
Postal code－））

Postal code－

Postal code－

Postal code－

Postal code－

Yes / No）））Yes / NoYes / No）Yes / No) months

Implementation method(Check all the applicable boxes)□ Oral□ Written (distribution of a questionnaire))□ Others (Yes / No

B. Language that the support is to be given in Language:
C. Scheduled hours of support

Name(Title)

）

□ Yes
□ No

Support staff or implementing staff if the support is to be outsourced□ Oral□ Written (including a translation))□ Others (Notes
1. Column I. If there are multiple persons who are to receive support and the contents of the support are the same, for “1 Name” write, “As given in the attached name list”, and attach a name list (no set format) which gives the matters set out incolumn I.
2. Column II-4: Fill in this section only if the organization of affiliation of the specified skilled worker itself is to implement the support plan for specified skilled workers (i).
3. Column III: Fill in this section only when entrusting the implementation of all of the support plans for specified skilled workers (i) to a registered support organization.
4. Attach a copy of the outsourcing contract if the organization of affiliation of specified skilled workers is to entrust all of the support given in Column IV-1 to 9 to a third party.
5. “Scheduled implementation” in Column IV-1 to 9: Check the applicable items, and if the scheduled implementation is “Yes”, briefly describe the implementation time, and if “No”, describe the reasons for not implementing the support in theparentheses.
6. Only tick "yes" for the "Outsourced" section in Column IV-1 to 9, if the organization of affiliation of the specified skilled worker is to entrust part of the support to a third party (excluding the cases when it is outsourced to a registered support
organization). If the organization of affiliation of the specified skilled worker itself is to provide support or entrust all of the support to a registered support organization, tick "no".
7. "Support staff or implementing staff if the support is to be outsourced" in Column IV-1 to 9: If the organization of affiliation of the specified skilled worker itself is to provide support or entrust all of the support to a registered support
organization, list the names of the appointed support staff, followed by their titles in parenthesis, for each type of support given. If a third party partly entrusted by the organization of affiliation of the specified skilled worker is to provide support,
list the names and addresses of staff entrusted for the support.
8. “Implementation method” in Column IV-1 to 4, 8 and 9: Check the applicable items. If you check “Others”, give the method of implementation in the parentheses.
9. “Size of the room” in Column 4-3, A, d”: If you checked “less than 7.5 m2 per person”, select the applicable box from within the parentheses to indicate whether the size of the room of the provided residence is at least 4.5 m2 or less than 4.5
m2.
10. “Response times” in Column IV-6, B: Give the times for the available days of the week.

I hereby declare that the support will be provided as described above.

In addition, this document has been translated into a language that the recipient of the support is fully able to understand, a copy has been given to the recipient of the support, and the contents
have been fully explained.
Name of the organization of affiliation of specified skilledworkers
Name of the person preparing this document
Seal

I have received a translation of this document in thelanguage, and I fully understand the contents having had them explained to me.
Date of signature
Signature of the specified skilled worker (i)DD/MM/YYYY参考様式第１－２４号
Reference Form 1-24

つうさんざいりゅう きかん

かかる せいやくしょ

通 算 在 留 期間に 係る 誓 約 書
E

A

E

E

AAE

EA

AE

EA

E

E

AA

E

E

A

E

E

Pledge for Total Period of Stay
とくてい ぎ の う いちごう

ざいりゅう し か く へ ん こ う き ょ か ま た

とくてい ぎ の う いちごう

か か る

「特定 技能 １号」への 在留 資格 変更 許可 又 は「特定 技能 １号」に 係る
ざいりゅう き か ん こ う し ん き ょ か

う

け

る

あ

た

っ

て

か

き

じ こ う

せいやく

在留 期間 更新 許可を 受ける に 当たって，下記の 事項について 誓約します。
In connection with receiving permission to change the status ofresidence to “Specified Skilled Worker (i),” or to extend the period of stayfor “Specified Skilled Worker (i),” I hereby pledge that I shall comply withthe following matter.
記
とくてい ぎ の う いちごう

つうさんざいりゅう き か ん

ごねん

た っ し た じてん

とくてい ぎ の う「特定 技能 １号」での 通算 在 留 期間 が ５年 に 達した 時点 で「特定 技能
いちごう

かつどう

しゅうりょうとくてい ぎ の う

ごう

いこう

ばあい

１号」の 活動を 終 了 し，「特定 技能２号」への 移行をする 場合等をの ぞ い て きこく

除いて 帰国 します。
I shall terminate activities concerning “Specified Skilled Worker (i)” at
the time when the total period of stay under the status of residence of“Specified Skilled Worker (i)” reaches five (5) years, and shall return to mycountry, excluding the case of changing my status of residence to“Specified Skilled Worker (ii).”

年月

DD/MM/YYYY

申請人署名
Signature of the applicant

日参考様式第５－７号
Reference Form 5-7

報酬支払証明書
Proof of Payment of Remuneration
月分（

月

日から

月

The remuneration for the month of１日 分）の報酬について，以下のとおり支払いました。
(from DD/MM to DD/MM) was paid as follows.

対象労働者
The worker for whom the payment was made①氏名（ローマ字）
Name (Roman letters)

②性
Sex

別

③生 年 月 日
Date of birth④国籍・地域
Nationality/region⑤在留カード番号
Residence Card No.

２

報酬
Remuneration①報酬総額
Total amount of
remuneration円
Yen②現金支給額Amount paid in cash

円
Yen

③支給日
Payment date

年月
DD/MM/YYYY（注意）(Notes)１ 上記２①は，控除前の報酬総額を記載すること。
The total amount of remuneration before deductions must be stated in ① of section 2 above.
２ 上記２②は，控除後の手取り報酬額を記載すること。
The amount of take-home pay after deductions must be stated in ② of section 2 above.

日

男 ・ 女
Male / Female上記の記載内容は，事実と相違ありません。
I hereby declare that the statement given above is true and correct.

年
DD

/

月

日

/

YYYY

MM

特定技能所属機関の氏名又は名称

Name of the organization of affiliation of the specified skilled worker
作成責任者 役職・氏名㊞

Name and title of the person responsible for preparing this document

Seal

給与支給者 役職・氏名㊞

Name and title of the salary payer

Seal

報酬について，雇用条件書どおりの報酬額であることを確認し十分に理解した上で，上記の内容どおり支給を受けました。
I have checked and fully understood that the amount of remuneration is just the same as what is statedin the Written Employment Conditions, and have received the above payment of remuneration.

年
DD

特定技能外国人の署名
Signature of the specified skilled worker

月
/

MM

日
/

YYYY

参考様式第５－８号
Reference Form 5-8

生 活 オ リ エ ン テ ー シ ョ ン の 確 認 書
Confirmation of Orientation for Life in Japan１

私の日本での生活一般に関する事項
General matters concerning my life in Japan

２ 私が出入国管理及び難民認定法第１９条の１６その他の法令の規定により履行しなければならない又は履行すべき国又は地方公共団体の機関に対する届出その他の手続に関する事項
Matters concerning notifications and other procedures which I must or should make to national or local
government agencies, pursuant to the provision of Article 19-16 of Immigration Control and Refugee
Recognition Act, and other laws and regulations.
３

私が把握しておくべき，特定技能所属機関又は当該特定技能所属機関から契約により私の支援の実施の委託を受けた者において相談又は苦情の申出に対応することとされている者の連絡先及びこれらの相談又は苦情の申出をすべき国又は地方公共団体の機関の連絡先
The contact information of the organization of affiliation of the specified skilled worker, the contact
information of the person who is in charge of handling my consultations and complaints and belongs to theparty that is entrusted with providing me with support pursuant to the contract with the organization ofaffiliation of specified skilled workers, and the contact information of the national or local government
agency where I should consult or make a complaint about the aforementioned organization/party ifnecessary, which I should understand.

４

私が十分に理解することができる言語により医療を受けることができる医療機関に関する事項
Matters concerning medical institutions where I can receive medical treatment in a language in which I
am reasonably fluent.

５

防災及び防犯に関する事項並びに急病その他の緊急時における対応に必要な事項
Matters concerning disaster prevention and crime prevention, and matters necessary for taking action ata time of sudden illness or other emergency.

６

出入国又は労働に関する法令の規定に違反していることを知ったときの対応方法その他私の法的保護に必要な事項
What to do if I notice a violation of provisions of laws and regulations regarding immigration or labor, andother matters necessary for my legal protection.
について，Date of explanation:

年

月

日

From: Time (年

月

From: Time (

:
日
:

時

分から

) to (:

時分から) to (:

時分まで) on DD/MM/YYYY
時分まで) on DD/MM/YYYY

年

月

From: Time (

日
:

時

分から

) to (:

時分まで) on DD/MM/YYYY

特定技能所属機関（又は登録支援機関）の氏名又は名称
Name of the organization of affiliation of the specified skilled worker (orregistered support organization)

説明者の氏名Name of the explaining party㊞
Seal

から説明を受け，内容を十分に理解しました。
I have received an explanation from the above person and fully understood the contents.

特定技能外国人の署名
Signature of the specified skilled worker

年月

DD/MM/YYYY日