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 examinationand 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 the attached
Written Employment Conditions.
This Employment Contract shall come into effect upon the specified skilled worker entering Japan with thestatus of residence of “Specified Skilled Worker (i)” or “Specified Skilled Worker (ii)”, or their statuschanges to one of the aforementioned statuses, and starts to engage in the activities for the work requiring
the skills provided for in an ordinance of the Ministry of Justice as stipulated by the Minister of Justice fora 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.
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□ Other (□ State of progress of the work done by the employee)

3. Limit on contract renewal (No / Yes (Up to _____ times / Total contract period of up to _____ years))[If the employee has executed a fixed-term employment contract with the same employer under the Labor Contracts Act, and thetotal contract period exceeds five years]
By requesting the employer to execute an employment contract with no fixed term (a non-fixed term employment contract) during
the term of the fixed term employment contract, the employee may change his/her employment contract to a non-fixed term
employment contract with effect from the day following the last day of the fixed term employment contract (DD/MM/YYYY). If thisapplies, will the working conditions in the non-fixed term employment contract be changed from those in the fixed-term employment
contract? (No / Yes (as described in Attachment 2))
II．Place of employment□ Dispatch employment (fill in the separate “Employment□ Direct employment (fill in below)

Conditions Statement”)(Immediately after hiring)(Extent of change) □ No possibility of change (If there is aName of officepossibility of change, provide details below.)

Address

Name of office ___________________________________

Contact information

Address _________________________________________
Contact information __________________________

III．Contents of work to be engaged in:(Immediately after hiring)
1. Field ((Extent of change) □ No possibility of change (If there is a)possibility of change, provide details below.)2. Wo rk catego ry ()

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 theagreement 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 ( ) mins

Start time ( : ) Finishing time ( : ); Day applied (); prescribed working hours for one day ( ) hours ( ) mins

Start 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 ( ) mins ② Month ( ) hours ( ) mins ③ Year ( ) hours ( ) mins
4. No. of prescribed working days ① Week (5. Overtime work

□ Yes

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

V．Days off
1. Regular days off: Every (2. Additional days off: (), national holidays, others () (total number of annual days off: ( ) days

) days per week/month, others ()○ Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.

VI．Leave
1. Annual paid leave Those working continuously for six months or more → () daysThose working continuously for up to six months（□ Yes □ No）→ After a lapse of ( ) months and ( ) days
2. Other leave

Paid () Unpaid ()

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 (yen)□ Daily wage (yen)□ Hourly wage (* 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(

4. Closing day of payroll
5. Pay day

□(

(

)%
) %，

Non-legal holiday work ()%□() of every month; () of every month; (6.Method of wage payment)%) of every month) of every month□ Bank transfer□ Payment in yen (cash)

7. Deduction from wages in accordance with labor-management agreement* Details given in the attachment.

□ No

□ Yes

)%

yen)

8. Wage raise
9. Bonus□ Yes (Timing，amount, etc.
□ Yes (Timing amount, etc.

10．Retirement allowance
11. Leave allowance) □ No) □ No□ Yes (Timing, amount, etc.

)

□ No

□ 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. Point of contact for matters concerning the improvement of employment management etc.
Name of department
Name of person in charge(Contact information)

５．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 thiscontract, the organization shall pay for the travel expenses and take necessary measures to ensure smooth departure.
Recipient（signature）

Any other matters shall be governed by the company’s Rules of Employment. Place and method of checking the Rules of Employment()

参考様式１－６

別紙１

Reference Form 1-6

Attachment 1

賃

金

の

支

払

PAYMENT OF WAGES
１．Basic Wages□ Monthly wage (yen) □ Daily wage (yen) □

Hourly 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 etc. 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)[If the worker is entitled to fixed overtime pay](e) (allowanceyen- Requirement for payment: An overtime allowance for __________ hours will be given regardless ofwhether the worker did overtime. The additional pay rate for overtime will be given for overtime
exceeding __________ hours.)
３．Estimated payment per month (1+2)

approx.

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

(b) Social insuranceyen)(approx.

(c) Employment insurance (approx.
(d) Food (approx.

yen)(e) Housing (approx.

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

yen)
yen)

yen)
yen)

yen (total)

(approx.

yen)(approx.

yen)(approx.

yen)(approx.

yen)Amount to be deducted

5．Take-home pay (3 - 4)

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１－６号 別紙２（雇用条件書Ⅰ.で【労働契約法に定める同一の企業との間での通算契約期間が５年を超える有期雇用契約の締結の場合】で有を選択した場合）
Reference Form 1-6, Attachment 2 (If the employee has executed a fixed-term employment contract with the same employer under the Labor
Contracts Act, and the total contract period exceeds five years, and if your answer to the question in the Written Employment Conditions I is
yes.)

雇

用

条

件

書

WRITTEN EMPLOYMENT CONDITIONS
The terms and conditions of an employment contract with no fixed term (a non-fixed term employment contract) that will come into
effect if the employee requests the employer to execute the non-fixed term employment contract during the term of his/her fixed term
employment contract are as follows:
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

No fixed term

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

Conditions Statement”)(Immediately after hiring)(Extent of change)□ No possibility of change (If there is aName of office ___________________________________

possibility of change, provide details below.)

Address _________________________________________Name of office ___________________________________

Contact information ________________________________

Address _________________________________________
Contact information _______________________________

III. Contents of work to be engaged in:(Immediately after hiring)(Extent of change)

1 . Field ()□ No possibility of change (If there is apossibility of change, provide details below.)

2 . Wo rk catego ry ()

1 . Field ()

2 . Wo rk catego ry ()

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, anda 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() hours (Week () hours (Week () days) minsMonth () hours () minsYear) mins

4. No. of prescribed working days
5. Overtime work

□ Yes

□

Month () daysYear () daysNo○ 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
1. Annual paid leave

Those working continuously for six months or more→(Those working continuously for up to six months (□ Yes) days□ No) → After a lapse of () months and ()

days
2. Other leave

Paid ()

Unpaid ()

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 (yen)□ Daily wage (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

(

) %,

Non-legal holiday work ()%)%

4. Closing day of payroll□() of every month; □ () of every month

5. Pay day□() of every month; □ () of every month

6. Method of wage payment□

Bank transfer□ 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.

)

□

No

9. Bonus□

Yes (Timing amount, etc.

)

□ No

10. Retirement allowance□

Yes (Timing, amount, etc.

)□

11. Leave allowance□

Yes (rate

No)

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() days before 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 daysof the average wage only when there are unavoidable reasons for the dismissal. In cases of dismissal based on a cause attributable tothe fault of the specified skilled worker, there is the possibility of immediate dismissal without giving advance notice or the average
wage being paid on approval being 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. Point of contact for matters concerning the improvement of employment management etc.
Name of department

Name of person in charge(Contact information)

5. If the specified skilled worker is unable to pay for the travel expenses to return to his or her home country after the termination ofthis contract, the organization shall pay for the travel expenses and take necessary measures to ensure smooth departure.
Any other matters shall be governed by the company’s Rules of Employment. Place and method of checking the Rules of Employment()

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 promote international
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, to myhome 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１－１６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 skilled

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

worker)（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。また，併せて当該情報が掲載されている画面の写しを添付すること。
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, Labour and Welfare.
Furthermore, attach a copy of the screen on which the information in question is posted.
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 theagent 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 placementbusiness provider, in the case where the job offeror uses the employment placement service provided by the employment placement businessprovider 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.

３

事前ガイダンスの実施
Conducting of guidance in advance

第１号特定技能外国人支援計画に定めるとおりに実施していることの有無
Is guidance being conducted according to "Support Plan for Specified Skilled

有 ・ 無
Yes/NoWorker (i)"?

以上の１から３までの内容について相違ありません。なお，求職者（申請人）が在留資格「特定技能」の活動を行うことに関連して保証金，違約金の支払等の不適切な費用徴収がされていないことを本人から聞き取るなどして確認しています。
There are no discrepancies with regard to 1 to 3 above. Further, it has been confirmed by, for example, asking
the person himself/herself that there has not been any inappropriate levying of fees such as a deposit or penalty
payment on the job seeker (applicant) in connection with his/her activities related to the "specified skilledworker" status of residence.

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 document４l

求職者（申請人）が自国等の機関に支払った費用
Fees paid by the job seeker (applicant) to organization in his/her country, etc.
支払先機関の名称

名目

支払年月日

支払金額

Name of

Name of item

Date ofAmount paidorganization towhich payment has

payment日been made
年 月

1

日

mm/dd/yyyy
年 月 日

2

mm/dd/yyyy
年 月 日

3

mm/dd/yyyy
年 月 日

4

mm/dd/yyyy
年 月 日

5

mm/dd/yyyy

（

円）

(

yen)

（

円）

(

yen)

（

円）

(

yen)

（

円）

(

yen)

（

円）

(

yen)
計

（

円）
Total

(

yen)

（注意）
(Notes)１ 自国等の機関は，特段対象を限定するものではなく，特定技能雇用契約の申込みの取次ぎ又は活動の準備に関与した全ての機関をいう。
The term "his/her country, etc." does not refer to particular institutions, but rather means institutions involved in accepting applications for
specific skilled employment contracts or in the preparation of activities, without limiting the scope of the subject matter in any particularway.
２ 支払金額については，現地通貨又は米ドルで記載し，括弧書きで日本円に換算した金額を記載すること。
With regard to "Amount paid," write it in local currency or US dollars and write in the parenthesis the value converted into yen.
３ 名目については，申請人に示した名目どおりに記載すること。
With regard to "Name of Item," write the name as expressed to the applicant.

特定技能雇用契約の申込みの取次ぎ又は在留資格「特定技能」に係る活動の準備に関して，自国等の機関に対し，上記の費用の額及び内訳について十分に理解した上で支払いました。また，
上記の費用以外の費用については，徴収されていません。
I have paid the above fees with amounts and details as described above to organizations in mycountry, etc. with a full understanding of the amount and breakdown of the costs involved inacting as an agent for applications for specified skilled worker employment contracts or in
preparing for activities related to the "specified skilled worker" status of residence. Furthermore,
no other fees other than the above have been collected from me.

申

請

人

の

署

Signature of the applicant

名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 of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.

１ 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

男 ・ 女
Male / Female③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日（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.

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

特定技能所属機関の氏名又は名称

/

MM

月

日

/

YYYY

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
給与支給者

l

役職・氏名

Name and title of the salary payer

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 isstated in 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 Japan２

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
the party that is entrusted with providing me with support pursuant to the contract with the organizationof affiliation 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
at a 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,
and other 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 partyl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

日

DD/MM/YYYY参考様式第５－９号

Reference Form No. 5-9

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 the activitiesof specified skilled worker (i), I fully understand the amount and breakdown of the expenses, and theorganization 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

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