Guidance from the Immigration Services Agency (1)～Procedures for applying for refugee status andcomplementary protection at the Immigration Bureau～
When you apply for refugee status or complementary protection at
the Immigration Bureau, you are always required to submit anapplication form(*). Please make sure that you have filled out theapplication form with all of the required information before queuingat the counter. If you do not fill out your application form with all of
the required information, you may be asked to finish filling out theapplication form and queue at the counter again.
Including this sheet, you can find further guidance and sample about how
to fill out the application form in plain English. This will help you tounderstand what information you should give in each question.
Please read further guidance and sample and use them as a reference
when you fill in the application form. If you do not know what to do, ask
an immigration official for help.
(*) Apply for refugee status if your life or body will be in danger once you return homebecause of your “race,” “religion,” “nationality,” “membership of a particular socialgroup” or “political opinion.”
Apply for complementary protection if your life or body will be in danger once you
return home because of a reason other than the above five reasons, such as a casewhere you have fled from your country because of the risk of getting involved in a
conflict arising there.

Guidance from the Immigration Services Agency (2)～Important points when filling out your application
form～Your application form is very important to examine your eligibility forrefugee status or complementary protection. Please provide any andall necessary information with as many details as possible. Follow
the matters listed below as well:・In principle, the application form must be filled out by the person who is applying
for refugee status or complementary protection.
Parents or guardians can write an application form for their child if they are under
16 years old.
・People who have difficulty in writing should ask an immigration official for help.
・If the answer to the question is left blank, we do not know if you forgot to answer itor you do not have anything to fill in. If you have no answer to write, write a cross(x) or a slash (/) in the answer space. If you cannot answer because you do notremember the answer, write “I do not remember.”・For questions where you have to choose an answer, write a check mark () for
each question to clearly show which one you have chosen.
・Do not use a pencil or an erasable pen.

< Sample >
難
法

民

・

補

完 的

保

護

対

象 者

認

定

申

請 書

務 大 臣 殿・Are you applying for refugee status or complementary protection?
・Check one box. You may not check both boxes.
・If you check “(1) Application for refugee status,” we will judge your eligibility both for refugee
status and for complementary protection.
If you check “(2) Application for complementary①難民認定申請（出入国管理及び難民認定法第61 条の２第１項の申請）
protection,” we will judge only your eligibility for complementary protection and will not judge youreligibility for refugee status.
②補完的保護対象者認定申請（出入国管理及び難民認定法第61 条の２第２項の申請）

私は、
☑
□

を行うものとして、本申請書を提出します。
※上記のうち、どちらか一つにチェックしてください。
・If you have a nickname, or①の申請をした場合には、補完的保護対象者の該当性についても判断されます。②の申請をした場合には、
another name different than・Write your name in Roman letters, the same way it is printed on your passport.
補完的保護対象者の該当性のみを判断します。
the one you already wrote on
・Write your last name (SURNAME) first and then write your first name (GIVEN NAME),
the same way it is printed on your passport.

氏 名男

Write down your date of birth innumbers (use 1,2,3, not One,
Two, Three).

NYUKAN ICHIROCircle or check(年)1990

(月)1

生年月日

Write your nationality and regionin Roman letters, the same way
国籍・地域（又は常居
it is printed on your passport.

所を有していた国名)女(✓) the answer(日)1 tothat applies
you.

出生地

the left, write it here.
・If you do not have a
別名・通称名等 nickname or other name, writea cross (X) or a slash (/) here.

IMMIGRATION ICHIRO

現在の職業

・Write down your current job.

×
・If you do not have a job,

write a cross (X) or a slash (/)
here.

・Write down the town where you were born.
・Write it the same way it is printed on your passport.

ABCDE

ODAIBA・Write down your phone number.
If you do not have a phone number, write
住居地
5-5-30,KONAN, MINATO-KU, TOKYO ・a cross (X) or a slash (/) here.
・Write down your current address in Japan.
・If you have a residence card, write down the
方 電話番号× 携帯電話番号〇〇〇-××××-△△△△
address written on your residence card.

番

号

発行・更新

有効期限

発行機関

発行・更新理由

2023.1.1

GOVERNMENTTRAVEL

Last day you can
use your passport(YYYY/MM/DD)

Institution thatissued your passport

Why did you getyour passport?

年月日
旅 券

A1234562022.1.1

Passport number

Date the passport
was issued(YYYY/MM/DD)

If you do not have a residence card,
write a cross (X) or a slash (/) here.

在留カード/

×

特別永住者証明書

Residence card
numberLast day you can use
your residence card
(YYYY/MM/DD)

本邦上陸年月日

上陸港

現に有する在留資格（又は許可の種類）

2023.1.1

NARITATEMPORARY VISITER

Day you arrived
in Japan

Airport or port
you arrived atCurrent status ofresidence in Japan

官 用 欄

在留期間満了日（又は許可の期限）2023.1.16
Last day of your period ofstay in Japan(YYYY/MM/DD)

Do not write anything in this space.
*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own applicationform.

•Write the information about your father on the first line and write about yourmother on the next line.
• If your father or mother have already died, write that.

家族構成
続柄

氏名

生年月日

性別

国籍・地

職業

域

NYUKAN父

1960.1.1

M

ABCDE

〇〇〇

NYUKAN

1965.1.1①

NYUKAN

BROTHERJIRO②

NYUKANSISTER

AIKO

F

ABCDE

電話番号

×

☐在日

〇〇〇CITY◇◇◇●●●●-

If this person is in Japan, check the
top box (resident in ×××
Japan). If thisperson is not in Japan, check thebottom box (resident×overseas).
〇〇〇CITY

☑在外

（計２人）

きょうだい

☐在日
☑在外

Write the information about all of yourbrothers and sisters.
HANAKO

居住地

在外

TARO
母

在日・

Write the total number of your brothers and sisters. For example, write 2 if you have one
brother and one sister.

1985.1.1

M

ABCDE

〇〇〇

〇〇〇CITY×☑在日

CHIOYODAKU

□□□-

☐在外

TOKYO

◎◎◎◎-

☐在日
☑在外

1992.1.1

F

ABCDE

〇〇〇

△△△△
③

④

☐在日

If you have blank spaces left after filling in theinformation about all of your brothers andsisters, write a cross (X) or a slash (/) in theblank spaces.

☐在外
☐在日
☐在外
☐在日

⑤

その他（配偶者、子、祖父母等）①

NYUKANWIFE

SACHIKO

Write down information on other members☐在外of yourfamily including wife, husband, children, grandfather,
grandmother, etc.

1993.1.1

F

ABCDE

〇〇〇

☑在日

MINATOKU

◆◆◆--

☐在外

TOKYO

〇〇〇〇▽▽▽▽

☐在日

②

③

If you have blank spaces left after filling in all theinformation about your spouse, children,
grandparents, etc., write a cross (X) or a slash (/) inthe blank spaces.

☐在外
☐在日
☐在外

④

☐在日
☐在外

⑤

☐在日
☐在外

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own application
form.

Write all the places you have lived (include where you lived and when you lived there). Include all
information about where you lived before you came to Japan and after you came to Japan.
Describe the places where you lived before coming to Japan in as much detail as possible.

居住地

居住期間

1990～2018.3

居住〇〇〇STREET,△△△CITY,

歴□□□PREFECTURE,ABCDE
2018.4~2021.12

×××STREET,◇◇◇CITY,●●●PREFECTURE,FGHI
Write down all theinformation aboutschools you haveattended, including
correspondence
schools.

◎◎◎PREFECTURE,JKLM
TOKYO,JAPAN
期間

学歴

2021.12~2023.1▽▽▽STREET,◆◆◆CITY,

2001~2007

2023.1~
学校名

種別

2007~20102010~2013

所在地

〇〇〇

☑初等,☐中等, ☐高等,

PRIMARY☐大学,☐その他SCHOOL2014～2018☑卒業,☐中退,☐その他☐初等, ☑中等,☐高SECONDARY等,SCHOOL☐大学,☐その他〇〇〇☐初等,☐中等,☑高等,

HIGHSCHOOL☐大学,☐その他☐その他☐初等,☐中等,☐高等,☐卒業,☐中退,☐大学,☐その他

☐その他

会社名等

〇〇〇

△△△CITY

卒業等〇〇〇☑卒業,☐中退,☐その他☐大学,☐その他

職歴△△△CITY

Check the box thatmatches the type ofschool you went to.

☐初等,☐中等,☐高等,期間

For each school, check thebox that matches your status(graduated, dropped out, orother).

業種〇〇〇△△△CITY☐卒業,☑中退,☐卒業,☐中退,
If you have blank spaces left
after filling in all theinformation about your educational background,
write a cross (X) or a slash ☐その他(/) in the blankspaces.

所在地△△△CITY

役職,業務内容□□□

COMPANY
Write down all the information about jobs you have held.

When you have blank spaces left after filling in all
the information about your work, write a cross (X)or a slash (/) in the blank spaces.

入国日
本邦
出入
国歴

2023.1.1
Day you came to
Japan

出国日

×
Day you left Japan(YYYY/MM/DD)

退去強制の有無×
Have you ever been deported from Japan?

If you have been to Japan before, write down the date youentered Japan and the date you left Japan. If you have been to
Japan more than once, write down all of your visits.

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own applicationform.

・If you have ever been to countries other than Japan, write them down.
・If not, write a cross (X) or a slash (/).

渡航先
海外渡航歴

部族・民族

渡航期間

〇〇〇〇

2018.4~2021.12

FOR STUDY□□□□

2022.1~2022.12

FOR WORKCountries you have beentoWrite down the date you enteredand the date you left each country.

その他可

宗教（宗派）

Write down your ethnicity.

使用言語
母国語

渡航理由

Your first language
Other languages

読むことWhat was the purpose of your stay?

Write down your religion or sect.

話すこと

書くこと

〇

〇

A LITTLE〇

A LITTLE×

能な言語
・Write your first language and other languages you can read, speak, and/or write.
・For each language, put a circle () for what you can do and a cross mark (X) or slash (/) for what you cannot do. If you can do alittle, then write “A little.”①難民認定申請を行う方は、１－１の質問から答えてください。

If you checked “(1) Application for refugee status” at the beginning of the application
form, fill in “1-1” and subsequent items. If you checked “(2) Application for（１－１の質問は答える必要がありません。
） and fill in "1-2" and subsequent items.
complementary protection,” skip “1-1”②補完的保護対象者認定申請を行う方は、１－２の質問に答えた後、２以降の質問に答えてください。

１－１ もしあなたが本国に戻った場合に、迫害を受ける理由は次のどれですか。
次のうちに該当する理由がない場合やこれ以外にも理由がある場合には、１－２に迫害を受ける理由を書いて
ください。
☐人種

・Check the boxes that match the reasons you think you will be persecuted if you go back to your country.
・If none of the reasons specified here apply or there is any other reason, write down the reason in “1-2.”

□宗教

□国籍

□特定の社会的集団の構成員であること□政治的意見
１－２ もしあなたが本国に戻った場合に、迫害を受ける理由を書いてください。

If none of the reasons specified in “1-1” above apply or there is any other reason for whichyour life or body will be in danger once you go back to your country, write down the reason.
２

Who will harm your life, well-being, etc. if you go back to your country?

（1）上記１－１又は１－２の理由により、あなたは誰から迫害を受けるおそれがありますか。
☐国家機関（名称等：

If it is an institution in your country, write the name） of the institution in parentheses ( ).

□上記以外（具体的に書いてください。
If you feel danger from someone other than an institution）
in your country, write
specific information in parentheses ( ).

（2）あなたが迫害を受けるおそれを感じたのはいつからですか。

・When was the first time you felt you would be persecuted?
・Write down specific year, month, and other information you remember.
（3）迫害を受ける理由、根拠を具体的に書いてください。

・Write down the reason why you will be persecuted if you return to your country. Include
as much detail as possible.
・This information is very important for examination, so describe the reason why you feel thatyou will be in danger, including what kind of danger you faced, when you faced it, and who
was a danger to you.

（注）この枠内に記載できない場合は別紙を提出して下さい。

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own application
form.

3

あなたが本国に帰国するとすれば、いかなる事態が生じますか。その具体的内容及び理由を書いてください。

・Describe in as much detail as you can what you think will happen
if you return to your country.
・This information is very important for examination, so describe
what kind of danger you will face, who will be a danger to you, andthe reason for that danger.

4（1）あなたは上記１－１又は１－２の理由より逮捕、抑留、拘禁その他身体の拘束や暴力等を受けたことがありますか。
□はい

☐いいえ

時期・期間

場所

行為者

行為の内容

理由

When were youarrested or
captured, or
exposed toviolence, etc.?
From YYYY/MMto
YYYY/MM

Where were
you arrested or
captured, or
exposed toviolence, etc.?

Who were
you arrested
or captured,or exposed toviolence, etc.
by?

What did they do
to you?

Why were you arrested
or captured, or exposed
to violence, etc.?

・Have you ever been arrested or captured, or been exposed to violence,etc. for the reason in the question 1-1 or 1-2.
・If you check Yes, answer the following questions. If you check No, you do
not have to answer these questions.
「はい」と答えた場合は、すべての事情について、具体的に書いてください。

（2）あなたは上記１－１又は１－２の事情以外に、逮捕、抑留、拘禁その他身体の拘束や暴力を受けたことがありますか。
□はい☐いいえ・Have you ever been arrested or captured, or been exposed to violence, etc. forreasons other than in the question 1-1 or 1-2.
・If you check Yes, answer the following questions. If you check No, you do nothave to answer these questions.

「はい」と答えた場合は、すべての事情について、具体的に書いてください。
時期・期間

場所

行為者

行為の内容

When were youarrested or
captured, or
exposed toviolence, etc.?
From YYYY/MMto
YYYY/MM

Where were youarrested or
captured, or
exposed toviolence, etc.?

Who were youarrested or
captured, or
exposed toviolence, etc.
by?

What did they do
to you?

理由

Why were you arrested
or captured, or exposed
to violence, etc.?

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own application
form.

5
（1）あなたの家族は上記１－１又は１－２の理由により逮捕、抑留、拘禁その他身体の拘束や暴力等を受けたこ・Has your family ever been arrested or captured, or been exposed to violence, etc.とがありますか。

□はい

☐いいえ

for the reason in the question 1-1 or 1-2.
・If you check Yes, answer the following questions. If you check No, you do not haveto answer these questions.

「はい」と答えた場合は、すべての事情について、具体的に書いてください。
氏名

続柄

Name of person
arrested or
captured, or
exposed toviolence, etc.

Relationship with
you

期間

場所

行為者

行為の内容

When were
they arrested
or captured,or exposed toviolence,
etc.?
From
YYYY/MMtoYYYY/MM

Where were
they arrested
or captured,or exposed toviolence, etc.?

Who were
theyarrested or
captured, or
exposed toviolence,
etc. by?

What did they do
to your family?

（2）あなたの家族は上記１－１又は１－２の事情以外に、逮捕、抑留、拘禁その他身体の拘束や暴力等を受けたことがありますか。

□はい

☐いいえ

・Has your family ever been arrested or captured, or been exposed to violence,etc. for reasons other than in the question 1-1 or 1-2.
・If you check Yes, answer the following questions. If you check No, you do nothave to answer these questions.

「はい」と答えた場合は、すべての事情について、具体的に書いてください。
氏名Name of person
arrested or
captured, or
exposed toviolence, etc.

6

続柄

時期・期間

場所

行為者

行為の内容

Relations
hip withyou

When were
they arrested
or captured,or exposed toviolence,
etc.?
From
YYYY/MMtoYYYY/MM

Where were
they arrested
or captured,or exposed toviolence, etc.?

Who were
theyarrested or
captured,or exposed
to violence,etc. by?

What did they do
to your family?

あなたは本国政府に敵対する組織(本邦を含む。)に属していましたか。
□はい

☐いいえ

・Were you part of an organization (including Japanese organizations) that
opposed your government?
・If you check Yes, answer the following questions. If you check No, you do nothave to answer these questions.

「はい」と答えた場合は、具体的に書いてください。
期間

組織名

役職

活動内容

When
From YYYY/MMto
YYYY/MM

What is the name oforganization you
belong to?

What was yourposition/status
in theorganization?

What did you do?

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own application
form.

7

あなたは本国政府に敵対する政治的意見を表明したり、行動をとったことがありますか。
（来日後にとった行動を含む。
）
□はい

☐いいえ

・Have you ever spoken your opinion against the politics of your country’s
government to people around you or acted against the government? This includes
things you have done after coming to Japan.
・If you check Yes, answer the following question. If you check No, you do not haveto answer the question.

「はい」と答えた場合には、具体的に書いてください。

・When, where and how did you speak your opinion against the politics of yourgovernment?
・Describe in detail when (approximate month and year), where (specific place inJapan or specific place in other countries), and what you did (held a demonstration,
posted your opinion on the Internet, etc.).
8

上記１－１又は１－２の理由によりあなたに対しての逮捕状の発付又は手配がなされていますか。
□はい

☐いいえ

・Do you have a warrant issued for your arrest or is someone trying to arrest or capture youin your country for the reason “1-1” or “1-2” above?
・If you check Yes, answer the following questions. If you check No, you do not have toanswer these questions.

「はい」と答えた場合は、具体的に書いてください。
年月日

機関名

罪状

When was anarrest warrant
issued for you or
when did someone
start trying to arrest
or capture you?
YYYY/MM/DD

What institution has
issued a warrant foryour arrest or istrying to arrest or
capture you?

If a warrant is issued for your arrest or
someone is trying to arrest or capture you ,what is the crime you are accused of?

上記事実をどのような方法で知ったのですか。
How did you know that a warrant had been issued for your arrest or that someone was trying to arrest or captureyou?

9

来日前、刑法犯罪を犯したことにより警察に逮捕され、検察官に起訴されたことがありますか。
□はい

☐いいえ

・Have you ever been arrested by the police or been on trial for violating the law before
coming to Japan?
・If you check Yes, answer the following questions. If you check No, you do not have toanswer these questions.

「はい」と答えた場合は、その刑事裁判の結果を書いてください。
年月日

裁判所名

罪名

判決内容

When were youon trial?
YYYY/MM/DD

Write the nameof the court
where your trial
was held.

What were you triedfor?

Write the result of the trial.

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own applicationform.

10 あなたは他の国に庇護を求めたことがありますか。
☐いいえ ・Have you ever asked for help from countries other than Japan?
・If you check Yes, answer the following questions. If you check No, you do nothave to answer these questions.

□はい「はい」と答えた場合は、具体的に書いてください。
国名

手続内容

結果

Which country did
you ask?

How did you ask?

Did you get any help
or not?

11 外国大使館、国連（UNHCR）に庇護を求めたことがありますか（来日前、来日後いずれも記載）
。
□はい

☐いいえ

・Have you ever asked for help from a foreign embassy or the United Nations (UNHCR)?
・If you have asked for help before or after coming to Japan, write about each of them.
・If you check Yes, answer the following questions. If you check No, you do not have toanswer these questions.

「はい」と答えた場合は、具体的に書いてください。
年月日

機関名

結果

When
YYYY/MM/DD

Foreign embassy or United
Nations (UNHCR)?

Did you get any help
or not?

12 あなたは、上記１－１から１１までに記載した内容を裏付ける資料を提出することができますか。
☐はい□いいえ ・Can you submit documents, pictures, or anything that can prove what
you wrote in questions 1-1 through 11 above to the immigration office?
・If you check Yes, answer the following questions. If you check No, you do
not have to answer these questions.

「はい」と答えた場合は、具体的に書いてください。
資料名

What do you have?

内容

提出理由

提出予定時期

What does it say?

Why do you want tosubmit them to theimmigration office?

When can you submit them tothe immigration office?

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own applicationform.

・Write down which countries you traveled through before you came to Japan, startingfrom the country where you were in danger.
・If you went to other countries, write down all the countries you went to.

13 あなたが迫害を受けるおそれのあった国から脱出した日から日本に上陸するまでの経緯について具体的に書いてください。複数の国を経由した場合には、すべて書いてください。
年月日

出国港

When
YYYY/MM/DD

年月日

From where?
（出発地）
Airport name
Port name

運送業者名

便名又は船名When
YYYY/MM/DD

To where?
（到着地）
AirportnamePort name

入国港

Ship orairlinecompany

Vesselnumber or
flight number

2018.3.××◇◇PORT2018.3.△△○○PORT○○

1234

2021.12.××○○PORT

2021.12.△△□□PORT□□

5678

You came to Japanstraight from yourcountry.

You came to Japan via
another country.

今回の日本への入国について該当するものに✓してください。
☐直行□第三国経由・When you came to Japan, did you come directly from your country? Or, did you come via another country?
・If you check the “via a third country” box, answer the following questions. If you check the “directly from yourcountry” box, you do not have to answer these questions.

第三国経由の場合は、該当するものに✓してください。
You changed ships or
airplanes in anothercountry.

□乗換え

□滞在

You lived in another country.

・Did you come to Japan via another country because you changed ships or airplanes, or because you lived
there?
・If you check the “You stayed in the country” box, answer the following questions. If you check the “You justtransited the country” box, you do not have to answer these questions.

第三国に定住した場合は、具体的に書いてください。
国名

滞在期間
(

What country
did you live
in?

~

滞在目的

生活状況

(電話番号))

From when to when
were you living there?
From YYYY/MMto
YYYY/MM

滞在場所

What was the
purpose of yourstay?

What town
did you livein?
(Telephone
Number)How did you live
there?

14 あなたは、日本で難民・補完的保護対象者認定申請ができることを、いつ、どこで、どのようにして知りましたか。

・When, where, and how did you come to know that you could apply
for refugee status or complementary protection in Japan?
・Provide details about when (approximate month and year), where(where in Japan, where in other countries, etc.) and how (Someone
told me, I saw it on the Internet, etc.).

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own application
form.

・How do you currently get the money for living in Japan?
・If you check the “Other money” box, write the detailed
information in the parentheses ( ).
15 現在の生活費用について何によって賄っているのか書いてください。

□給与

□預金
By a bank deposit

By Salary

☐その他（

）

OthersIf you check the “By Salary” box, answer the following questions.
If not, you do not have to answer these questions.

「給与」と答えた場合は、書いてください。
会社名
Write the name of thecompany that pays thesalary.

給与の額

月給・日給の別Monthly pay□月給How much do you get
paid?

□日給

Daily pay

If you check the “By a bank deposit” box, answer the following「預金」と答えた場合は、書いてください。 questions.
If not, you do not have to answer these questions.

金融機関名

Name of the bank, etc.

預金残高

口座の種類・番号

The amount of money savedin the bank

Bank account number

If you check the “Others” box above and are receiving money from someone else, answer the following questions.
If not, you do not have to answer these questions.

「その他」と答えた場合で、第三者から金銭的支援を受けている場合は、書いてください。
支援団体又は支援者名

期間(

Who do you receive money
from?

~

支援金額
)

From when to when did you
receive money?
YYYY/MM to YYYY/MM

Money received in one
year

(円/年)

Money received in a
month

(円/月)

16 在外親族に送金をしたことがありますか。・Have you ever sent money to your family or relatives living in a country
□はい

☐いいえ

other than Japan?
・If you check Yes, answer the following questions. If you check No, you do
not have to answer these questions.

「はい」と答えた場合に、書いてください。
氏名

The name of theperson you sent
the money to.

続柄Relationship with
you

送金額

金融機関名

The amount ofmoney you sent

Name of thebank, etc.

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own applicationform.

17 来日後 6 月以内に難民・補完的保護対象者認定申請を行っていない人は、申請が遅れた理由を具体的に書いてください。

If you did not apply for refugee status or complementary protection at the
Immigration Bureau within 6 months after coming to Japan, write down thereason why you could not apply during that period.

18 来日後、刑法犯罪を犯したことにより警察に逮捕され、検察官に起訴されたことがありますか。
□はい

☐いいえ

・Have you ever been arrested by the police or had a trial for violating the law aftercoming to Japan?
If you check Yes, answer the following questions. If you check No, you do not have to・「はい」と答えた場合は、その刑事裁判の結果を書いてください。
answer these questions.

年月日

裁判所名

罪名

判決内容

When
YYYY/MM/DD

Name of the
court

What crime?

Outcome of thetrial

19 第三国への渡航を希望しますか。
□はい

☐いいえ

・Do you want to go to a country other than Japan?
・If you check Yes, answer the following questions. If you
check No, you do not have to answer these questions.

「はい」と答えた場合は、渡航先国及びその理由を具体的に書いてください。

・Write down the country you want to go to.
・Write the reason why you want to go to that country.

20 迫害を受けるおそれ以外の理由で、本国に帰国できない理由があれば、具体的に書いてください。

Is there any reason you cannot return to your own country other than the reason why
you will be persecuted if you return to your country?

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own application
form.

・Are you well now?
・If you check the “Poor” box, answer the following
21 現在の健康状態はどうですか。
question. If you check the “Good” box, you do not have to☐良好
answer the following question.

I am in good
health condition.

□不良「不良」と答えた場合は、その状況を具体的に書いてください。

I am in poor healthcondition.

・Provide detailed information on your poor health condition.
・Write down what part of your body is unwell or in pain.

22 難民調査官がインタビューする場合、通訳は必要ですか。
☐はい

□いいえ

・Do you need an interpreter when you are interviewed?
・If you check Yes, answer the following questions. If you check No,
you do not have to answer these questions.

必要とする場合は何語を希望しますか。

語
What language would you like an interpreter for?

その他通訳に関して希望する事項があれば、理由とともに書いてください（例：通訳人の性別、国籍）。

Write down any specific requests you have for interpretation of the interview.
Write down the reason for your request as well.
(Example: I would like to have a male/female interpreter because XXX.)

23 難民調査官がインタビューする場合に、通訳に関すること以外で配慮してほしいことがあれば、理由とともに記入してください。
（例：難民調査官の性別）

With respect to an interview, write down any request other than for aninterpreter.
Write down the reason for your request as well.
(Example: I would like to be interviewed by a male/female refugee inquirer
because XXX.)

以上の記載内容は、事実と相違ありません。

Make sure there are no mistakes in what you have written above.

申請者（代理人）の署名
If there are no mistakes in what
you have written above, sign
here.

年

月

日

Write down the date (YYYY/MM/DD) of submitting
the application form to the immigration office.

*The name (NYUKAN ICHIRO) on this application form is a sample. Do not copy that onto your own applicationform.