日本国政府法務省Ministry of Justice,Government of Japan
法務大出厳To the Minister of Justice町出入国管理及び離民認定法第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。 Pursuant to the provisions of Paragraph 2 of Article 21 of the Immigration Control and Refugee Recognition Act, I hereby apply for extension of period of stay. Photo 1国籍・地域Nationality/Region 2生年月日Date of birth Given name年Year月山Day 3氏名Family name Month Name 4別男・女姓Sex Male/Female 5配偶者の有無有・伸Married / Single Marital status 7本国における居住地6業Occupation Home town/city 8住居地Address in Japan 9電話番号Telephone No. 10旅券(1)番#f Number Passport 11現に有する在留資格Status of residence在留期間の満了日Date of expiration年Year月Day田在留期間Period of stay Month 12在留カード番号Residence card number 13希望する在留期間Desired length of extension (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.) 14更新の理由Reason for extension 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)華/ 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
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 not required to fill in item 16 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.)携帯電話番号Cellular phone No. (2)有効期限Date of expiration年月山Year Month Day For applicant, part 2  P ("Student") 17通学先Place of study (1)名称Name of school (3)電話番号(2)所在地Telephone No. Address (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 19 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口卒業口休学中□中退口在学中(1)在籍状況Registered enrollment      Graduated Temporary absence Withdrawal In school口専門学校口大学院（博士）   口大学院（修士）  口大学口短期大学Doctor Master Bachelor Junior college College of technology口高等学校口中学校□小学校□その他（ ) Others Senior high school Elementary school Junior high school (3)卒業又は卒業見込み年月(2)学校名月# Year Month Date of graduation or expected graduation Name of the school 20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))口試験による証明     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ロ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Organization年年期間:町　から月　までPeriod from Year Month       to Month Year口その他Others 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) Japanese education history (Fill in the following when you 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年年期間:町からまで
町to Year Month Year Month Period from 22 滞在費の支弁方法等(生活費,学費及び家貨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)口在外経費支弁者負担口本人負担F Self Yen Supporter living abroad口袋学令口在日経費支弁者負担田Scholarship Supporter in Japan Yen口その他田田Yen田Yen Others Yen (2)送金・携行等の別Remittances from abroad or carrying cash田口外国からの携行口外国からの送金田Carrying from abroad Yen Remittances from abroad Yen ）口その他田(携行者携行時期Name of the individual Date and time of Yen Others carrying cash carrying cash (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(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
電話番号Telephone No.電話番号Telephone No. (4)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 22(1) is supporter living abroad or Japan)口祖父口父口母口卷父口共口夢口茶母口祖母Husband Wife Father Mother Grandfather Grandmother Foster father Foster mother口受入教育機関口兄弟姉妹口叔父(伯父) •叔母(伯母)口友人・知人Friend / Acquaintance Brother / Sister Uncle / Aunt Educational institute口取引関係者・現地企業等職員口友人・知人の親族Relative of friend / acquaintance      Business connection / Personnel of local enterprise口取引関係者・現地企業等職員の親族□その他( Relative of business connection / personnel of local enterprise Others (5)竣学金支給機関 (上記(1)で竣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口外国政府□日本国政府口地方公共団体Foreign government Japanese government Local government口公益社団法人又は公益財団法人（ ）ロその他（ Public interest incorporated association / Others Public interest incorporated foundation 23資格外活動の有無有・無Are you engaging in activities other than those permitted under the status of residence previously granted? Yes / No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Fill in (1) to (4) when your answer is "Yes".    (Give the information for all of the companies if the applicant works for multiple companies)*another paper may be attached, which does not have to use a prescribed format. (1)内容Type of work (2)勤務先名称Place of employment電話番号Telephone No. (3)週間稼働時間Work time per week (4)報時間Hour(s) Salary円（口月額口日額 ） Yen Monthly Daily 24  卒業後の予定Plan after graduation口日本での進学口帰国Return to home country Enter a school of higher education in Japan口その他（口日本での就職Find work in Japan Others 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) (2)本人との関係(1)氏名Name Relationship with the applicant (3)住所Address電話番号Telephone No.携帯電話番号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Address電話番号Telephone No.携帯電話番号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 filing in this form年月山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，事名すること。社意In cases where descriptions have changed after filling in this application form up until submission of this application,  the applicant Attention (legal representative) must correct the part concerned and sign their name. Agent or other authorized person ※取次者(1)氏名(2)住所Address Name (3)所属機関等(親族等については,本人との関係) Organization to which the agent belongs (in case of a relative, relationship with the applicant)電話番号Telephone No. Year Month Day