在留資格認定証明書交付申請（表紙）

APPLICATION FOR CERTIFICATE OF ELIGIBILITY

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Email *
1. 国籍・地域
(Nationality / Region) *
2. 生年月日
(Date of birth) *
MM
/
DD
/
YYYY
3. 氏名 (Name) *
4. 性別 (Sex) *
5. 出生地 (Place of birth) *
6. 配偶者の有無
(Marital status) *
7. 職業（例：会社員、自営業、無職など）
 (Occupation) *
8. 本国における居住地
(Home town / city) *
9-1. 日本における連絡先
(Address in Japan)
9-2. 電話番号
(Telephone No.)
9-3. 携帯電話番号
(Cellular phone No.) *
10-1. 旅券番号
(Passport Number) 
10-2. 旅券有効期限
(Passport Date of expiration)
MM
/
DD
/
YYYY
11. 入国目的
(Purpose entry. check one of the followings) *
12. 入国予定年月日
(Date of entry)
MM
/
DD
/
YYYY
13. 上陸予定港
(Port of entry)
Clear selection
14. 滞在予定期間
(Intended length of stay)
15. 同伴者の有無
(Accompanying persons, if any)
Clear selection
16. 査証申請予定地
(Intended place to apply for visa)

17. 過去の出入国歴
(Past entry into / departure from Japan)

Clear selection
17-1. 回数 (time(s))
17-2. 直近の出入国歴
(The latest entry from)
MM
/
DD
/
YYYY
17-2. 直近の出入国歴
(The latest entry to)
MM
/
DD
/
YYYY
18. 過去の在留資格認定証明書交付申請歴
(Past history of applying for a certificate of eligibility)
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18-1. 回数 (time(s)) 
(Fill in the followings when the answer is "Yes")
18-2. うち不交付となった回数 (time(s))
 (Of these applications, the number of times of non-issuance）)
19. 犯罪を理由とする処分を受けたことの有無
 (Criminal record (in Japan / overseas)※Including dispositions due to traffic violations, etc.) *
20. 退去強制又は出国命令による出国の有無
(Departure by deportation /departure order)
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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 and others) and anyone you currently reside with)
Clear selection
A copy of your responses will be emailed to the address you provided.
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