Work Certificate

Form No. 1-2 (Re: Articles 2, 6, 16 and 20)

To Mayor of Ota City
In A.D

Date of certification

YearMonthDay

Office Name
Name of RepresentativeAddress
TEL

―

―

Name of the person incharge
Contact――

I hereby certify that the following information is true.
If you make or alter the contents of this certificate without the permission of the business or other entity where you work, you may be charged with a crime undercriminal law.
No.

1List

Type of Business

Description□ Agriculture andforestry□ Fishing□ Information andCommunication□□□ Mining, quarrying, and gravel
extraction
Transportation andPostal Services□ technical services Education and Learning Support

2345Construction□ Wholesale and retail trade□ Lodging and food services

Academic research and professional□□ Combined services□ Finance and insurance□□ Public service

Mo
nthYearYear

Day ～Year

10

Taking leave other thanmaternity/childcare leave

11(Planned) date ofreinstatement

Availing the shortened
working hour system for12childcare*Includes acquisitionschedule
Whether or not you
actually work as a13
childcare worker, etc.
14MonthMonthDay

DayAddress□ Full-timeEmployee□ Part-time Job□ SelfemployedPerson□ Self-employed Full-timeWorker

Mon Tues Wed Thurs

FriSat Sun□

□□

□□□□

□ Family Employee

Public holidays□□

TemporaryEmployee□

Totalhours□

Contract
Employee

Fiscal Year
Contracted Staff□ HomeJob□ Subcontracting

MonthlyHours□ Part-time/
Temporary Staff□ Scheduled to acquire□ Acquiring□ Acquired

Period

Month

Year

Day ～

□ Scheduled to acquire□ Acquiring□ Acquired

PeriodMonthYear□ Scheduled to acquire□ Acquiring
Main working
hours/shift hours□ YesHr.

MonthYearYear

MonthBoard
MemberMin)

minutes)(Break timeDayminutes)
minutes)minutes)minutes)minutes)MonthYear

Hours／MonthDay

Day□ Sick leave□ Nursing care leave

Day ～□ Scheduled to return□ Returnedto workto work

MonthYearreason□□ Others (Number of working days perMonthly
Week
Number of working days per monthDayweek
Weekday
Hr.
Min～
Hr.
Min Break time(sSaturday
Hr.
Min～
Hr.
Min Break time(s6SundaysandHr.
Min～
Hr.
Min Break time(Holidays
Total hours
Hours□ Monthly□ WeekMin Break time(Working hours
Number of workingDay□ Monthly□ Week
(in case of irregular work)
days
Main working
Hr.
Min ～Hr.
Min Break time(hours/shift hours
Work record
Year andYear andYear andMontMontYear
Year*Number of days
MonthMonthMonthhh
includes paid vacation.
7
Hours includes breaks
Day／Day／Day／
Hours／Month
Hours／Monthand overtime
MonthMonthMonth
Taking prenatal and□ Scheduled to acquire□ Acquiring
postnatal leave
8*Includes plans
Period～YearMonthDayYear
Month9Real estate andproperty rental）

Working hours(For fixed employment)

Taking childcare leave*Includes plans□

NameCompany where theapplicant works

Type of Employment

Period (If indefinite, only start date ofemployment)□ Fixed term

Electricity, gas, heat
supply, and watersupply□ Others （Date ofBirth□ Indefinite□□ Medical care and welfare

Lifestyle-related services
and entertainment

Name of the applicant

Employment (planned)
period, etc.

□ Manufacturing□ Others（）

Day
Day

PeriodYear

Min ～Hr.

MonthDay ～

Year

Month

Min （Break timeminutes）

MonthYearDay□ Yes（scheduled） □ No

Remarks column

Additional entry field
15 Single/Overseas assignment*Includes plans
There is a ☑ in No.3 fixed term → whether the contract
16 will be renewed or not
Number of working days(planned) for those who falls under
17No.12□ Yes□ No□ Yes

□ No□ MonthlyPeriod□ WeekYearDay

Day ～MonthDay