How to Fill in the Application for Certificate of Eligibility
Please read through carefully as you complete filling in the application form.
“For applicant, part 1”, all sections MUST be filled in.
No. 1, 2, 3, 5 and 10: Please make sure every information is in strict correspondence with your passport.
No. 4, 6, 15, 17, 18, 19 and 20: Please circle the suitable one.
No. 8: Please write in your precise city and country where you live in now.
No. 11: Please check “P (Student)”.
No. 12 and 13: If your plan hasn’t been fixed at this point, please put the following date and port as atentative schedule:
Date of entry: 20**/03/15 (for spring starters), 20**/09/15 (for fall starters)
Port of entry: Kansai International Airport
No. 14: If you are to study for one semester, please answer “6 months”.
No. 21: If you have no family or co-residents in Japan, please answer “none”.
“For applicant, part 2”, Please leave No. 25 and 26 blank.
No. 22 (1): If you are a graduate student, please change the Name of school to “神戸大学大学院国際文化学研究科”.
No. 23: Please note that “Total period of education” refers to the beginning of elementary school throughthe expected graduation from your university.
No. 24 (1): Please tick two sections:
1. In school
2. Doctor / Master / Bachelor
No. 27: (1) Please fill in the monthly amount. The amount must be at least 100,000 Yen.
(2) Please answer each information of your supporter(s).

“For applicant, part 3”, Only No. 27 and 28 needs to be filled in.
No. 27: If you have supporter(s) and/or have obtained scholarship, please tick (3) and/or (4).
Please note that an attachment of proof such as a copy of recent bank statement, bank book, certificateof the scholarship, etc. will be mandatory. This is to prove that all expenses while in Japan can becovered.
No. 28: Please tick “帰国(Return to home country)”.
No. 29, 30 and signature: Please leave this space blank.

2021/4/16

Photograph requirements | Immigration Services Agency of Japan

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Photograph requirements

The photograph submitted with each application should meet the following requirements.
Examples of both appropriate and inappropriate photographs have been provided for reference, so please ensure that all submissions meet the standards.
(mm)

Photograph size
4 cm long, 3 cm wide
The photograph must contain only the applicant.
The dimensions of the photograph must meet those shown on the left (excluding the edges).
(The dimensions of the face are measured from the top of the subject's head (including their hair) to the tip of their chin.)
The applicant must face the camera and cannot wear a hat.
There must be no background (including no shadow).
It must be a clear photograph.
It must be taken within three months of the date of submission.
The applicant's name must be written on the back.

Examples of appropriate photographs

These photographs meet all of the requirements listed above and show the subject clearly.

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2021/4/16

Photograph requirements | Immigration Services Agency of Japan

Examples of inappropriate photographs

Photographs that do not meet the specifications listed above.

Subject is notcentered

Subject's face isturnedShadows in thebackground

Subject is leaning

Subject's glasses
are reflecting light

Subject's face ispartially hidden by amask

Photographs where the face is partially obscured.

Subject's glasses
are obstructing theireyes

The frames of thesubject's glasses are
too thickSubject's hair ispartially covering
their eyes

Subject's head
covering is casting ashadow(Note) Head coverings
are allowed provided
that the applicant's
face is clearly visible.

Photographs where it is difficult to identify the person.

Subject's expression
is not neutral

Subject's facial
contours are
obscured by a dark
background

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別記第六号の三様式（第六条の二関係）

SAMPLE

申請人等作成用 １
For applicant, part 1

日本国政府法務省
Ministry of Justice, Government of Japan

Photo must be taken
within three (3) months
prior to submission.

在 留 資 格 認 定 証 明 書 交 付 申 請 書
APPLICATION FOR CERTIFICATE OF ELIGIBILITY
法務大臣

殿

写 真

To the Minister of JusticePhoto

出入国管理及び難民認定法第７条の２の規定に基づき，次のとおり同法第７条第１項第２号に掲げる条件に適合している旨の証明書の交付を申請します。

40mm×30mm

Pursuant to the provisions of Article 7-2 of the Immigration Control and Refugee Recognition Act, I hereby apply forthe certificate showing eligibility for the conditions provided for in 7, Paragraph 1, Item 2 of the said Act.

1 国 籍・地 域2 生年月日

CANADIAN

Nationality/Region年

1994

Date of birth

月

5Year日15MonthDay

FAMILY NAME GIVEN NAME [MIDDLE NAMES]*Fill in your name as printed on passport (In Chinese character too if you are a Chinese/Korean).

3 氏 名
Name

Family name

4 性 別男・女

SexMale/Female

7 職 業
Occupation

Given name

5 出生地

CANADA, MONTREAL

Place of birth

8 本国における居住地

STUDENT

電話番号

無/Single

携帯電話番号

078-803-7530

Telephone No.

(1)番 号

Passport・Married〒657-8501 神戸市灘区鶴甲1-2-1 神戸大学国際人間科学部鶴甲第一キャンパス事務課教務学生係

Address in Japan

10 旅券

有Marital status

CALGARY, CANADAHome town/city

9 日本における連絡先

6 配偶者の有無(2)有効期限

ABC100000

Number"Instructor"□ Ｌ 「企業内転勤」"Nursing Care""Skilled Labor"□ Ｖ「特定技能（1号）」□ Ｎ 「研究」"Business Manager”"Researcher""Designated Activities (Graduate from a university in Japan)"■ Ｐ 「留学」"Entertainer""Student"□ Y 「技能実習（2号）」"Technical Intern Training ( i )""Designated Activities(Dependent of Gradutate from a university in Japan)"□ Ｔ「永住者の配偶者等」"Spouse or Child of Japanese National"□ Ｔ「定住者」"Spouse or Child of Permanent Resident""Long Term Resident"□ 「高度専門職（1号イ）」□ 「高度専門職（1号ロ）」□ 「高度専門職（1号ハ）」"Highly Skilled Professional(i)(a)""Highly Skilled Professional(i)(b)""Highly Skilled Professional(i)(c)"

12 入国予定年月日

年

2022

Date of entry

14 滞在予定期間

Year

3

月日

15Month

13 上陸予定港

Day

16 査証申請予定地□ Ｕ 「その他」
OthersKANSAI INTERNATIONAL AIRPORTPort of entry

15 同伴者の有無

1 YEAR or 6 MONTHS

Intended length of stay

"Dependent"□ Ｒ「特定活動（本邦大卒者家族）」"Designated Activities(Dependent of EPA)""Designated Activities (Dependent of Researcher or IT engineer of a designated org)""Trainee"□ Ｒ 「家族滞在」"Technical Intern Training ( ⅲ )"□ Ｒ「特定活動（EPA家族）」□ Ｔ 「日本人の配偶者等」□ Ｑ 「研修」□ Y 「技能実習（3号）」"Technical Intern Training ( ⅱ )"□ Ｒ 「特定活動（研究活動等家族）」"Journalist""Engineer / Specialist in Humanities / International Services"□ Ｏ 「興行」"Specified Skilled Worker ( ⅱ ) "□ Ｌ「報道」□ Ｎ「特定活動（本邦大学卒業者）」"Designated Activities ( Researcher or IT engineer of a designated org)"□ Ｖ「特定技能（2号）」□ Y 「技能実習（1号）」

Day□ Ｎ 「技術・人文知識・国際業務」□ Ｎ「特定活動（研究活動等）」"Specified Skilled Worker ( i ) "日13Month"Religious Activities"□ M 「経営・管理」"Researcher (Transferee)"□ Ｎ 「技能」□ Ｋ 「宗教」"Cultural Activities"□ Ｌ 「研究（転勤）」"Intra-company Transferee"

月5YearPurpose of entry: check one of the followings□ Ｊ 「文化活動」"Artist"□ Ｎ 「介護」

年

2026

Date of expiration

11 入国目的 （次のいずれか該当するものを選んでください。）□ Ｉ 「教授」□ Ｉ 「教育」□ Ｊ 「芸術」"Professor"

Leave here blank

Cellular phone No.

有 ・ 無

Accompanying persons, if anyYes/No

CALGARY, CANADA

Intended place to apply for visa

17 過去の出入国歴

有 ・ 無Past entry into / departure from Japan
Yes / No
（上記で『有』を選択した場合） (Fill in the followings when the answer is "Yes")

回数2回

直近の出入国歴time(s)The latest entry from年

2015

18 過去の在留資格認定証明書交付申請歴

Year

12

月

28

Month日からDay

to2016

年
Year

1月

3Month日Day

有 ・ 無Past history of applying for a certificate of eligibility

Yes（上記で『有』を選択した場合）(Fill in the followings when the answer is "Yes")

/No

回数回
time(s)回（うち不交付となった回数）
Leave here blank（Of these applications, the number of times of non-issuance）

time(s)19 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)※Including dispositions due to traffic violations, etc.

有 （具体的内容）

・ 無

Yes ( Detail:)/

20 退去強制又は出国命令による出国の有無
Departure by deportation /departure order（上記で『有』を選択した場合）(Fill in the followings when the answer is "Yes")

No有 ・ 無Yes

回数/No回

直近の送還歴年

月日

time(s)The latest departure by deportation

YearMonthDay

21 在日親族（父・母・配偶者・子・兄弟姉妹・祖父母・叔(伯)父・叔(伯)母など）及び同居者
Family in Japan (father, mother, spouse, children, siblings,grandparents, uncle, aunt or others) and cohabitants

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 同居予定の有無

Relationship

Name

Date of birth

Nationality/Region

NONE

Intended to residewith applicant or notNo

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

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.
21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 21, 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.)（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。
Note : In case of to be found that you have misrepresented the facts in an application, you will be unfavorably treated in the process.

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

申請人等作成用 ２

Ｐ （「留学」）

在留資格認定証明書用

For applicant, part 2 P ("Student")

22 通学先(1)名 称For certificate of eligibility

Place of study

神戸大学 国際人間科学部 or 大学院国際文化学研究科

Name of school(2)所在地(3)電話番号〒657-8501 神戸市灘区鶴甲1-2-1

Address

23 修学年数 （小学校～最終学歴）

Registered enrollment■ 在学中

DoctorMaster□ 高等学校

□ 中学校(2)学校名Name of the school□ 休学中

In school

■ 大学
□ 小学校

Junior high schoolWithdrawal□ 短期大学

Bachelor

UNIVERSITY OF XXXX

□ 中退

Temporary absence□ 大学院 （修士）

Senior high school

Years

Education (last school or institution) or present school

Graduated□ 大学院 （博士）年

17Total period of education (from elementary school to last institution of education)

24 最終学歴 （又は在学中の学校）(1)在籍状況□ 卒業

078-803-7530

Telephone No.

Elementary school□ 専門学校Junior college

College of technology□ その他 （）Others(3)卒業又は卒業見込み年月

年

202X

Date of graduation or expected graduation

YearXX月
Month

25 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 the applicant plans to study at advanced vocational school or vocational school(except Japanese language))
Proof based on a Japanese language test
□ 試験による証明
Name of the test
Attained level or score（１）試験名（２）級又は点数□ 日本語教育を受けた教育機関及び期間
機関名

Organization and period to have received Japanese language education

Organization

期間：
Periodfrom

年

月

から年

月

Year

MonthtoYear

MonthLeave here blank□ その他
Othersまで

26 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）
Japanese education history (Fill in the followings when the applicant plans to study in high school)

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
Organization and period to have received Japanese language education / received education by Japanese language

機関名Organization

期間：Periodfrom年

月から年月

Year

MonthtoYear

Monthまで

27 滞在費の支弁方法等（生活費，学費及び家賃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
Method of support and an amount of support per month (average)(1)支弁方法及び月平均支弁額□ 本人負担
Self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OthersYen

100,000円
Yen円□ 奨学金円YenScholarship

Yen(2)経費支弁者（複数人いる場合は全てについて記入すること。）※任意様式の別紙可
Supporter(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.

①氏 名
Name

NAME OF YOUR SUPPORTER(S)88 CANADA OLYMPIC ROAD SW, CALGARY,CANADA③職業 （勤務先の名称）
ENGINEER (ABC Co. Ltd.)
②住 所

電話番号

Address

Telephone No.

Occupation (place of employment)

Telephone No.

④年 収
Annual income

5,000,000円
Yen

電話番号+1 403 xxx xxx+1 403 yyy yyy

申請人等作成用 ３Ｐ （「留学」）

在留資格認定証明書用

For applicant, part 3 P ("Student")

For certificate of eligibility(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）
Relationship with the applicant (Check one of the followings when your answer to the question 27(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

Foster father□ 受入教育機関

Uncle / Aunt

□ 友人・知人の親族□ 養父

Grandmother□ 養母
Foster mother□ 友人・知人

Educational institution

Friend / Acquaintance□ 取引関係者・現地企業等職員Relative of friend / acquaintanceBusiness connection / Personnel of local enterprise□ 取引関係者・現地企業等職員の親族□ その他 （Relative of business connection / personnel of local enterprise）

Others(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 scholarship (Check one of the following when the answer to the question 27(1) is scholarship) * multiple answers possible□ 外国政府Foreign government□ 日本国政府□ 地方公共団体

Japanese government

Local government□ 公益社団法人又は公益財団法人 （28）

Public interest incorporated association /Public interest incorporated foundation
Plans after graduation卒業後の予定■ 帰 国□ その他 （Fill in the correct name of thescholarship organization□ 日本での進学

Return to home country）

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

29 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

Name

Relationship with the applicant(3)住 所Address

電話番号

携帯電話番号

Telephone No.

Cellular Phone No.

30 申請人，法定代理人，法第７条の２第２項に規定する代理人
Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.

(1)氏 名(2)本人との関係

Name

Relationship with the applicant(3)住 所Address

電話番号

携帯電話番号

Telephone No.

Cellular Phone No.

Leave here blank

以上の記載内容は事実と相違ありません。
申請人（代理人）の署名／申請書作成年月日

注 意Attention

I hereby declare that the statement given above is true and correct.
Signature of the applicant (representative) / Date of filling in this form

年月日

YearMonthDay

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（代理人）が変更箇所を訂正し，署名すること。
申請書作成年月日は申請人（代理人）が自署すること。
In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant (representative) must correct
the part concerned and sign their name.
The date of preparation of the application form must be written by the applicant (representative).

Agent or other authorized person※ 取次者(1)氏 名Name(3)所属機関等(2)住 所Address
Organization to which the agent belongs

電話番号

Telephone No.