There are three sheets in the Excel file.
Fill in all three sheets referring to the sample.

別記第三十号の二様式（第二十一条関係）

To make（DO NOT USE WHITEOUT）.
日本国政府法務省
申請人等作成用
１ corrections, cross off with a double line and sign your initials
For applicant, part1

Ministry of Justice,Government of Japan

在 留 期 間 更 新 許 可 申 請 書SAMPLE

写 真

APPLICATION FOR EXTENSION OF PERIOD OF STAYYour photo must have been taken

Photo
within the last 3 months
and be40mm ×30mm in size. Not necessary
To the Minister of Justicewhen submitting to Ritsumeikan
出入国管理及び難民認定法第２１条第２項の規定に基づき，次のとおり在留期間の更新を申請します。
3. Write your name in the Alphabet as written on（Must attach when submitting to thePursuant to the provisions yourof Paragraph
2 of Article
21 ofiftheyour
Immigration
Controlincludes
and Refugee Recognition Act,Residence
Card.
card also
Immigration Office）
I hereby apply for extensionyourof periodof stay.
namewritten in Kanji, please include yourname in Kanji here as well.
年月
1 国 籍・地 域
2 生年月日CHINA
2000
121 日
法務大臣殿Nationality/Region

YearDate of birth

3 氏 名

EX: RITSUMEI TARO (立命Name
Family nameMonth太郎)

7. Enter your hometown inyour home country.

Given name→

4 性 別男 ・ 女

5 配偶者の有無

有 ・ 無

Sex

Male/Female

Marital status

Married / Single

6 職 業
8 住居地
9 電話番号
Telephone No.

○○ City, ○○Province, China

Home town/city

ROOM ○, ○○APARTMENTS, 1-2-3 ○TOWN, KITA-KU, KYOTO

Address in Japan

10 旅券

7 本国における居住地

Student

Occupation

携帯電話番号
4. 5. Move the circle to the appropriate option.

090-1234-5678

Cellular phone No.

(1)番 号

PassportDay

11 現に有する在留資格
在留期間の満了日

2022

Date of expiration

12 在留カード番号

在留期間
6月
Month

13 希望する在留期間

4 years

Desired length of extension

1Year月日

1MonthDay

2 years

Period of stay

ER12345678LFResidence card number

Reason for extension

年Year年

2028

Date of expiration

Student

Status of residence

14 更新の理由(2)有効期限M123456

Number20 日

Day

11. You must apply within the 3 months
prior to this date.
（審査の結果によって希望の期間とならない場合があります。）( It may not be as desired after examination.)

EX: TO CONTINUE MY UNIVERSITY STUDIES

15. Select either"Yes" or "No".

15 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。） Criminal record (in Japan / overseas)
有 （具体的内容） ・ 無
Yes ( Detail:)/No

16 在日親族（父・母・配偶者・子・兄弟姉妹など）及び同居者
Family in Japan(Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents

有 （「有」の場合は，以下の欄に在日親族及び同居者を記入してください。） ・ 無
Yes (If yes, please fill in your family members in Japan and co-residents in the following columns)

続 柄

氏 名

生年月日

国 籍・地 域

Relationship

Name

Date of birth

Nationality/Region

16. Select either "Yes" or "No".
Circle"Yes" if you have any co-resident or familymember living in Japan, and fill in the details .

同居の有無
Residing withapplicant or not/No

勤務先名称・通学先名称
Place of employment/ school

在 留 カ ー ド 番 号
特別永住者証明書番号
Residence card number
Special Permanent Resident Certificate number

有・無Yes / No有・無Yes / No有・無Yes / No有・無Yes / No有・無Yes / No有・無Yes / No※ 3について，有効な旅券を所持する場合は，旅券の身分事項ページのとおりに記載してください。
Regarding item 3, if you possess your valid passport, please fill in your name as shown in the passport.
16については，記載欄が不足する場合は別紙に記入して添付すること。なお,「研修」，「技能実習」に係る申請の場合は，「在日親族」のみ記載してください。
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 only required to fill in your family members in Japan for applications pertaining to “Trainee” or “Technical Intern Training”.

（注） 裏面参照の上，申請に必要な書類を作成して下さい。 Note : Please fill in forms required for application. (See notes on reverse side.)申請人等作成用 ２Ｐ （「留学」）

在留期間更新・在留資格変更用For applicant, part 2 P ("Student")

For extension or change of status

17 通学先 Place of study(1)名 称立命館大学 衣笠キャンパス

Name of school(2)所在地(3)電話番号

京都市北区等持院北町56-1

Address

075-465-8230

Telephone No.

18. & 19. Fill in if you are applying for the first time since enrolling at Ritsumeikan（18及び19は在留資格変更許可申請又は進学若しくは転学の場合に記入）(Fill in 18 and 19University.
in case of applying for a change of status, going to a higher school or changing your school)
18 修学年数 （小学校～最終学歴）
年
EX: 14
Total period of education (from elementary school to last institution of education)Years

19 最終学歴 （又は在学中の学校） Education (last school or institution) or present school(1)在籍状況 19. Mark□ "In卒業■ 在学中□ 休学中□ 中退 18. Do not include
Registered enrollment
Graduated
In school
Temporary absence
Withdrawal
time studying atschool" and your□ 大学院 （博士）□ 大学院 （修士）
■ 大学
□ 短期大学 Japanese□ 専門学校Language
Doctor current
MasterBachelor
Junior college
College of technology
School.
programme level.
□ 高等学校□ 中学校□ 小学校□ その他 （）Senior high school(2)学校名

Junior high school

立命館大学

Name of the school

Elementary school

Others(3)卒業又は卒業見込み年月

2026

Date of graduation or expected graduation

年Year3月
Month20 日本語能力 （専修学校又は各種学校において日本語教育以外の教育を受ける場合に記入）
Japanese language ability (Fill in the followings when you study at advanced vocational school or vocational school (except Japanese language))□ 試験による証明 Proof based on a Japanese Language Test
（１）試験名 Name of the test（２）級又は点数 Attained level or score

20. Fill in if relevant to you.
□ 日本語教育を受けた教育機関及び期間 Organization and period to have received Japanese language education
機関名
22. Fill in the total amount ofOrganization
tuition
期間：年
月 から年fee and living
月 expenses
まで
permonth.
YearMonthtoYearMonthPeriod from【Example】□ その他
Others-Tuition fee
Yearly tuition fee 974,600 yen ⇒approx. 81,000 yen per month
21 日本語学習歴 （高等学校において教育を受ける場合に記入） - Living expenses
Japanese education history (Fill in the following when you study in high school)
Monthly living expenses 100,000
日本語の教育又は日本語による教育を受けた教育機関及び期間
yen by Japanese language
Organization and period to have received Japanese language education / received education
21. You may leave this section blank.
81,000 + 100,000 = 181,000 JPY
機関名Organization(the amount to fill in)
期間：年
月 から年
月 まで
Year

Period fromMonthtoYearMonth

22 滞在費の支弁方法等（生活費，学費及び家賃等全てについて記入すること。）※複数選択可
Method of support to pay for expenses while in Japan(fill in with regard to living expenses, tuition and rent) * multiple answers possible(1)支弁方法及び月平均支弁額 Method of support and an amount of support per month (average)□ 本人負担
Self

Monthly amount of funding
covered by the applicant円□ 在外経費支弁者負担

Yen

Supporter living abroad□ 在日経費支弁者負担
Supporter in Japan□ その他円Others

Yen円

□ 奨学金

Yen

Scholarship(2)送金・携行等の別 Remittances from abroad or carrying cash
If you/someone carried cashinto 円□ 外国からの携行□ 外国からの送金
Carrying from abroad（携行者Name of the individualcarrying cash

the country for you

Yen

携行時期Who?

Date and time ofcarrying cash

Remittances from abroad

When ?

Monthly amount of support
provided from outside of Japan
Amount of scholarshipyou
receive (if any)

Same Amount as in above"Supporter living abroad"） □ その他

円
Yen円
Yen円
Yen

円

OthersYen

22. (3) Fill if you entered something for(3)経費支弁者（複数人いる場合は全てについて記載すること。）※任意様式の別紙可"Supporter living abroad" or "Supporter inSupporter(If there is more than one, give information on all of the supporters )*another paper may be attached, which does not have to use a prescribed format.
Japan" in section 22(1).
①氏 名 Use Alphabet or Japanese Kanji
Name②住 所 Full address in Englishor Japanese, including room
Address number③職業 （勤務先の名称）

EX: COMPANY EMPLOYEE (○○Occupation (place of employment) CORPORATION)④年 収

Annual income

電話番号
Telephone No.

Yearly amount 円

Yen

電話番号
Telephone No.

Home/personal phone
Work phone

申請人等作成用 ３

Ｐ （「留学」）

在留期間更新・在留資格変更用For applicant, part 3 P ("Student")

For extension or change of status

Please mark（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）
off the description for your supporter.
(4)申請人との関係
Relationship with the applicant (Check one of the followings when your answer to the question 22(1) is supporter living abroad or Japan)□夫□妻

Husband■父Wife□母Father□ 兄弟姉妹□ 祖父Mother□ 祖母Grandfather□ 叔父 （伯父）・叔母（伯母）Brother / Sister

Uncle / Aunt

□ 友人・知人の親族□ 養父Grandmother□ 養母

Foster father□ 受入教育機関

Foster mother□ 友人・知人

Educational institute

Friend / Acquaintance□ 取引関係者・現地企業等職員

Relative of friend / acquaintanceBusiness connection / Personnel of local enterpriseMark off if relevant to you . (Ex: JASSO□ 取引関係者・現地企業等職員の親族□ その他 （Scholarship recipient, etc. ...)
Relative of business connection / personnel of local enterprise
Others）(5)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 scholarship (Check one of the following when the answer to the question 22(1) is scholarship)* multiple answers possible□ 外国政府□ 日本国政府

Foreign government□ 地方公共団体

Japanese government

Local government□ 公益社団法人又は公益財団法人 （Are you currently working） a□part-time
その他 （job?
Public interest incorporated association /Public interest incorporated foundation）

Others有・無23 資格外活動の有無

Yes / NoAre you engaging in activities other than those permitted under the status of residence previously granted?

有の場合は，(1)から(4)までの各欄を記入（複数ある場合は全て記入すること）※任意様式の別紙可
If youforare,
the details
here. works for multiple
all offill
the incompanies
if the applicant
Fill in (1) to (4) when your answer is "Yes". (Give the informationcompanies)*another paper may be attached, which does not have to use a prescribed format.

(1)内 容Convenience store staff

Type of work(2)勤務先名称
Place of employment(3)週間稼働時間
Work time per week

電話番号○○ convenience store1224 卒業後の予定 Plan after graduation□帰 国時間(4)報 酬

Hour(s)Salary円 （ ■ 月額 □ 日額 ）48,000Yen

Monthly

DailyMark off your future plan.

□ 日本での進学

Return to home country

12345678

Telephone No.

Enter a school of higher education in Japan■ 日本での就職□ その他 （Find work in JapanOthers）

25 本邦における申請人の監護人（通学先が中学校又は小学校の場合に記入）
Actual guardian in Japan(Fill in the following if the applicant is to study at a junior high school or elementary school)(1)氏 名(2)本人との関係
Relationshipwithblank.
the applicant
You may leave thissectionName(3)住 所
Address

電話番号

携帯電話番号

Telephone No.

Cellular Phone No.

26 代理人（法定代理人による申請の場合に記入）(1)氏 名Name

Legal representative (in case of legal representative)(2)本人との関係
Relationship with the applicant(3)住 所

You may leave this section blank.

Address

電話番号

携帯電話番号

Telephone No.

Cellular Phone No.

以 上 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.
申請人（法定代理人）の署名／申請書作成年月日 Signature of the applicant (legal representative) / Date of filling in this form
年Do not sign when submitting to Ritsumeikan
Year（Sign and date when submitting to immigration office）.

月日MonthDay

注 意 申請書作成後申請までに記載内容に変更が生じた場合，申請人（法定代理人）が変更箇所を訂正し，署名すること。
Attention In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant(legal representative) must correct the part concerned and sign their name.

※ 取次者(1)氏 名Name

Agent or other authorized person(2)住 所
Address

You may leave this section blank.
(3)所属機関等（親族等については，本人との関係）
電話番号
Organization to which the agent belongs (in case of a relative, relationship with the applicant)Telephone No.