Application form for Certificate of Eligibility for Status of Residence (CESR)
在留資格認定証明書交付申請フォーム

Please check and read this document carefully and also refer to "NOTE" in blue.
This is the system to enter a CESR application form.
これは在留資格認定証明書（CESR）の申請書を作成するためのシステムです。
Please enter the required items in English or Japanese and click “Confirm”.
英語または日本語で必要事項を入力して、確認ボタンを押してください。
Note : In case of to be found that you have misrepresented the facts in an application, you will be unfavorably treatedin the process.
注 : 申請書に事実に反する記載をしたことが判明した場合には、不利益な扱いを受けることがあります。

Fill in all required items with ＊＊は入力必須項目
The information registered on this site will be protected via encrypted transmission (SSL) and will bemanaged securely by "Spiral", a database-management ASP service provided by PIPED BITS Co.,Ltd.,
which is certified by JIPDEC Privacy Mark, ISO27001/JIS Q 27001, ISO 20000-1, and ISO 9001
standards.

ご登録される情報は、暗号化された通信(SSL)で保護され、 プライバシーマークやISO27001/JIS Q 27001,ISO20000-1, ISO9001の認証を取得している 株式会社パイプドビッツによる情報管理システム「スパイラル」で安全に管理されます。

Nationality/ Region

1.国籍・地域

Nationality/ Region

国籍・地域 ＊CANADIAN

Date of birth

2.生年月日Date of birth

生年月日 ＊

2003

Year年 1Month月

1Day日

Name

3.氏名Please enter your name with upper letter in the order of Family name, Given name in the same alphabetic characters as shown on yourpassport. DO NOT use special alphabet like ù, â, ë and so on.
パスポートに記載されているとおり、姓→名の順番に、英字（大文字）で名前を入力してください。 ù, â, ëなどの特殊なアルファベットは使わないでください。
Even though you hold a passport issued by China, Hong Kong or Taiwan, please enter your name in alphabetic characters only.
中国、香港、台湾 のパスポートの方も、英字で名前を入力してください。

Example/例：KOBE TARO

Name

氏名 ＊

KOBE TARONOTE:
Please input all UPPER LETTER in English.

Gender

4.性別Male/男Gender

性別 ＊Female/女Place of birth

5.出生地
Please enter the Country, State (Province) and City where you were born.
出生地の国、省/州/県/市を入力してください。
Example/例：China, Fujian Province, Fuzhou city
U.S.A., Massachusetts, Boston

Place of birth

出生地 ＊Canada, Ontario, Toronto

Marital status

6.配偶者の有無

Marital status

配偶者の有無 ＊Married/有Single/無Occupation

7.職業
Please enter your current job status, not your prospective status at Kobe University
現在の職業を記載してください。神戸大学受入後の身分は入力しないでください。
Please enter "unemployed" if there is a period after graduation before you enroll in Kobe University.
Example：Graduated in June, 2023 and enrolled in Kobe University in October, 2023
大学卒業後、神戸大学入学までに期間がある場合は「無職」と入力してください。
例：2023年6月卒業、2023年10月神戸大学入学

Occupation

職業 ＊Student
NOTE:Exchange students must enter "Student".

Home town/ city

8.本国における居住地
Please make sure to enter your residential country, state(province), city of your current address.
現在住んでいる場所の国、州（県）、都市名を記入してください。

Home town/ city

Canada, B.C., Vancouver

The e-mail address to receive CESR.

Same

本国における居住地 ＊在留資格認定証明書送付メールア
ドレス ＊

NOTE:
Please input "Same".
Basically, your CoE will be sent to your email address you registered when application.

Passport

9.旅券

If you are currently applying for a passport, please enter "pending".
パスポートを現在申請中の場合、「pending」と入力してください。

Number(1)旅券番号 ＊Date of expiration(2)旅券有効期限

XX0000000
NOTE:
If your passport is due to expire during the exchange period, it is highly recommended that you renew it prior toyour application of VISA. If you are applying for it now, please enter "Pending".

2033

Year年 1Month月1Day日

Expected date of your entry into Japan

10.入国予定年月日

Expected date of your entry into Japan

入国予定年月日 ＊2024

Year年 9Month

月Day27 日

NOTE:DO NOT purchase a flight ticket before you get the Acceptance Letter!!

Port of entry

11.上陸予定港
Please enter the name of the airport or port name where you are planning to enter Japan.
入国する際の日本の予定空港、港の名前を入力してください。
Example/例：Kansai International Airport

Port of entry

上陸予定港＊

NOTE: This port could be changed later.
== Major International Airport in Japan ==<Osaka>- Kansai International Airport<Tokyo>- Tokyo International Airport (This is HANEDA)- Narita International Airport (This is NARITA)

Kansai International Airport

Intended length of stay

12.滞在予定期間
Please enter the period for which you have been accepted to Kobe University.
Example：6 months / 1 year / 2 years / 3 years
神戸大学での在籍予定期間を入力してください。例：6か月/1年間/2年間/3年間

Intended length of stay

滞在予定期間＊NOTE:- Students staying for 1 semester enter "6 months"- Students staying for 2 semesters enter "1 year".

6 months or 1 year

Accompanying persons, if any

13.同伴者の有無

Accompanying persons, if any

同伴者の有無 ＊Yes/有No/無NOTE:“Accompanying persons” does NOT mean persons who enter to Japan at thesame time. For example, exchange students from the same home university
who come to Japan together or families who travel to Japan with you before
your exchange program are not considered as "Accompanying persons"here.

Intended place to apply for visa

14.査証申請予定地
Please enter the city name where you intend to apply for a visa. The city must have a Japanese embassy or consulate.
Please refer to the website below.
査証申請をする日本大使館または総領事館のある市の名前を入力してください。
下記のウェブサイトを参照してください。
https://www.mofa.go.jp/about/emb_cons/mofaserv.html

Intended place to apply for visa

Vancouver, B.C., Canada

査証申請予定地＊

Past entry into / stay in Japan

15.日本への過去の出入国歴
Have you ever visited or lived in Japan?
これまでに日本に来たことがありますか？

Yes/有Past entry into / stay in Japan

日本への過去の出入国歴 ＊No/無If above answer is "yes", please enter details below.

上記で『有』を選択した場合は以下に詳細を入力してください。
time(s)

1 回time(s)回数

The latest entry from(start)

2023

The latest entry to(end)2023

直近の出入国歴開始

直近の出入国歴終了

YearMonthYearMonth年 3年 4月月Day27 日5Day日

Past history of applying for a certificate of eligibility

16.過去の在留資格認定証明書交付申請履歴
Have you ever applied for a visa certificate so far?
これまでに在留資格認定証明書を申請したことがありますか？

Past history of applying for a

Yes/有certificate of eligibility

No/無過去の在留資格認定証明書交付申
請履歴 ＊

NOTE:
This question is whether you had applied for CoE before, NOT VISA.
If you choose "Yes" here, do NOT forget to answer these questions.

If above answer is "yes".

上記で『有』を選択した場合time(s)回数time(s)

1 回

Of these the number of time of non-issuance.

上記のうち不交付となった回数

time(s)

回数time(s)

0 回

NOTE:
You should input here even if the answer is "0".

Criminal record (in Japan/ overseas)

17.犯罪を理由とする処分を受けたことの有無 （日本国外におけるものを含む。）※交通違反等による処分を含む。

Criminal record (in Japan/ overseas)

犯罪を理由とする処分を受けたことの有無 （日本国外におけるものを含む。）※交通違反等による処分を含む。 ＊Yes/有No/無If above answer is "yes", please enter details below.

上記で『有』を選択した場合は以下に詳細を入力してください。

Details

具体的内容

Departure by deportation/ departure order

18.退去強制又は出国命令による出国の有無
Have you ever departed Japan by deportation or departure order?
退去強制または出国命令により日本から出国したことがありますか？

Departure by deportation/ departure

Yes/有order

No/無退去強制又は出国命令による出国の有無 ＊If above answer is "yes", please enter details below.

上記で『有』を選択した場合は以下に詳細を入力してください。
time(s)回time(s)

回数

The latest departure by deportation

直近の送還歴Year年

Month月Day

日

Family or co-residents in Japan

19.既に日本に滞在する家族及び同居者の有無
Do you have any family members (Father, Mother, Spouse, Son, Daughter, Brother, Sister, or others) or co-residents living in Japan?
日本に住んでいる家族（父、母、配偶者、息子、娘、兄弟、姉妹他）や同居する方がいますか？

Family or co-residents in Japan

既に日本に滞在する家族及び同居者の有無 ＊Yes/有No/無If above answer is "yes", please enter details below.

上記で『有』を選択した場合は以下に詳細を入力してください。
First person

1人目

Relationship

続柄Name氏名

Date of birth

生年月日

Year年

Month月Day日

Nationality/ Region

国籍・地域

Intended to reside with applicant or

Yes/有notNo/無

同居予定の有無

Place of employment/ school

勤務先名称・通学先名称

Residence card number/ Special
Permanent Resident Certificate
number

在留カード番号・特別永住者証明
書番号
Second person

2人目

Relationship

続柄Name氏名

Date of birth

生年月日

Year年

Month月Day日

Nationality/ Region

国籍・地域

Intended to reside with applicant or

Yes/有notNo/無

同居予定の有無

Place of employment/ school

勤務先名称・通学先名称

Residence card number/ Special
Permanent Resident Certificate
number

在留カード番号・特別永住者証明
書番号
Third person

3人目

Relationship

続柄

Name

氏名

Date of birth

生年月日

Year年

Month月Day日

Nationality/ Region

国籍・地域

Intended to reside with applicant or

Yes/有notNo/無

同居予定の有無

Place of employment/ school

勤務先名称・通学先名称

Residence card number/ Special
Permanent Resident Certificate
number

在留カード番号・特別永住者証明
書番号
Fourth person

4人目

Relationship

続柄

Name

氏名

Date of birth

生年月日

Year年

Nationality/ Region

国籍・地域

Intended to reside with applicant or

Yes/有notNo/無

同居予定の有無

Place of employment/ school

勤務先名称・通学先名称

Month月Day日

Residence card number/ Special
Permanent Resident Certificate
number

在留カード番号・特別永住者証明
書番号
If there is not enough space in the given columns to write in all of your family in Japan, fill in and upload a separate sheet.

記載欄が不足する場合は別紙に記入してアップロードしてください。

The attached file concerning family inJapan

ファイルの選択 ファイルが選択されていません

在日親族別紙添付ファイル

Total period of education prior to entering Kobe University (from elementary school to the last institution of education)

20.神戸大学に入る前までの修学年数（小学校～最終学歴）

Years13 年

Total period of education prior toentering Kobe University (fromelementary school to the lastinstitution of education)

神戸大学に入る前までの修学年数（小学校～最終学歴）＊<e.g.>
If you are a 2nd year student of undergraduate, please add up below;- The period of Elementary school: 6 years- The period of (junior) high school: 6 years- The period of University: 1 year
Therefore 6+6+1= 13 years
You don't need to include the year of kindergarten.

Education (last school or institution) or present schoolEducation (last school or institution) or present school

21.最終学歴 （又は在学中の学校）

Graduated/卒業

Present Academic Status

現在の在籍状況＊NOTE:
Exchange students must choose "In school".

In school/在学中
Temporary absence/休学中
Withdrawal/中退

Your status at the schoolYour status atDoctor/大学院（博士）

the school

Master/大学院（修士）在籍区分＊Bachelor/大学

NOTE:
Please choose one which corresponds to your present degree.
(Either Bachelor, Master, or Doctor)

Junior college/短期大学College of technology/専門学校
Senior high school/高等学校
Junior high school/中学校
Elementary school/小学校
Others/その他

Name of the school

ABC University

Date of graduation or expected2025

学校名 ＊graduation

卒業又は卒業見込み年月 ＊YearMonth年 月

NOTE:Please enter the date of expected graduation from your homeuniversity. The date must be the same as the one listed on theapplication form.

Method of support to pay for expenses while studying at Kobe University（Please enter living expenses, tuition and rent)*
multiple answers possible

22.神戸大学在籍中の経費支弁方法等（生活費、学費及び家賃について記入してください。）※複数選択可
Method of support and an amount of support per month (average)(1)支弁方法及び月平均支弁額※複数選択可

More than 100,000 yen per month is

Self/本人負担
Yenrequired.

40,000 円

月額100,000円以上必要 ＊NOTE:
The total amount must be over JPY100,000/month.
Proofs of financial supports in English which correspond tothe methods of support you choose here must be uploadedin the final section. For more details, please check theinformation sheet and application guide that we sent.

Supporter living outside of Japan/在外経費支弁者負担
Yen

60,000 円
Supporter in Japan/在日経費支弁者負担
Yen円
Scholarship/奨学金
Yen円
Others/その他
Yen円

Financial supporter（Please enter the following items when your answer to the question 22(1) is a supporter living
outside of or in Japan.) (If there is more than one, give information for all of the supporters)*another paper may beattached, which does not have to use a prescribed format.

(2)経費支弁者（上記(1)で在外経費支弁者負担又は在日経費支弁者負担を選択した場合に記入） （複数人いる場合は全てについて記入してください。）※任意様式の別紙可

Name

氏名

KOBE HANAKOAddress

住所

Please input an address of your financial supporter above.

Telephone No.

+1-000 000 0000

電話番号

Occupation (place of employment)

Engineer (ABC Ltd.)

Phone number at work

+1-111 111 1111

職業 （勤務先の名称）

勤務先電話番号

Annual income (place of employment)

年収The attached file concerning thesupporter

経費支弁者別紙添付ファイル

NOTE:
Both an occupation and a place of employment arenecessary. In case of self-employment or retired,please enter as follows;"Self-employment (Name of company)" or"Occupation (Retired)".

Yen

5,000,000 円

ファイルの選択 ファイルが選択されていません

Relationship with the applicant (Check one of the followings when your answer to the question 22(1) is supporter living
outside of or in Japan)* multiple answers possible(3)申請人との関係（上記(1)で在外経費支弁者負担又は在日経費支弁者負担を選択した場合に記入）※複数
選択可

Husband/夫

Relationship with the applicant

申請人との関係

Wife/妻Father/父Mother/母Grandfather/祖父Grandmother/祖母
Foster father/養父
Foster mother/養母Brother/Sister/兄弟姉妹
Uncle/ Aunt/叔父（伯父）・叔母（伯母）Educational institution/受入教育機関
Friend/ Acquaintance/友人・知人
Relative of friend/ acquaintance/友人・知人の親族
Business connection/ Personnel of local enterprise/取引関係者・現地企業等
職員
Relative of business connection/ personnel of local enterprise/取引関係者・現地企業等職員の親族
Others/その他

Organization which provide scholarship (Check one of the following when the answer to the question 22(1) isscholarship)* multiple answers possible(4)奨学金支給機関（上記(1)で奨学金を選択した場合に記入）※複数選択可

Organization which provide

Foreign government/外国政府

scholarshipJapanese government/日本国政府

奨学金支給機関

Local government/地方公共団体
Public interest incorporated association/Public interest incorporated
foundation/公益社団法人又は公益財団法人

Others/その他

Plans after graduation or completion of the program at Kobe University

23.神戸大学卒業後またはプログラム修了後の予定
Please select “Enter a school of higher education in Japan”, if you would like to enter the Graduate School soon after completion of a
Research Student period.
研究生が研究期間終了後，すぐに大学院に進学を希望する場合は，「日本での進学」を選択してください。
NOTE:
Exchange students must choose "Return to home country".

Plans after graduation or completion of

Return to home country/帰国the program at Kobe University

Enter a school of higher education in Japan/日本での進学

神戸大学卒業後またはプログラム修了後の予定 ＊Find work in Japan/日本での就職
Others/その他

NOTE:The same photo as your passport should be avoided. It must be taken within 6 months. Also, it
must NOT be photoshopped. Please refer URL below. Since this site is in Japanese, click a blue
button at the left bottom corner and choose "English".

Digital Photo

顔写真＊

ファイルの選択 ファイルが選択されていません*It is preferable to submit highquality digital photo data in formats
such as "jpg" or "png". *The photomust meet all specifications which
can be checked in the following
website.
https://www.moj.go.jp/isa/applications/procedures/photo_info_00002.html

Passport

パスポート
Copy of Passport ID Page
*All letters on the ID page must beshown clearly.

Proof of financial support

経費支弁証明書類＊Status

編集ステータス ＊ファイルの選択 ファイルが選択されていません
NOTE:
The passport copy must be clear. Please check it before submission.
In addition, please check the expiration date. If you don't have a valid passport now, please
upload a copy of your previous passport or ID.

ファイルの選択 ファイルが選択されていません

Temporarily stored/一時保存

NOTE:
Please upload here the documents thatprove the "Method of support to meet the expenses
while studying at Kobe University." [Question 22]
To check what kinds of documents are acceptable,please refer to the Application Guide.

Entered/入力済

確認/Confirm
NOTE:
Please choose "Temporary stored" once you fill in the CoE Online application form.
Once we review it, we will inform you to change the status to "Entered" again.