Notification to the Immigration

(left the organisation)

Dear ALT,

If you are a foreign national with a Residence Card and a visa status that permits
employment, you are required to submit an official notification form to the Immigration
office within 14 days AFTER the date of any change in your workplace.

If:
□ You have a RESIDENCE CARD
and
□ Your current visa status is “INSTRUCTOR”
please follow the instructions below.

・・・・ INSTRUCTIONS ・・・・

1) Complete both the form and list provided

2) Post both the form and list with a photocopy of your residence card (both sides)
within 14 days AFTER the date of your final work assignment to the Notification
Acceptance Desk, Residency Management Information Department, Tokyo Regional
Immigration Bureau at 5-5-30 Konan, Minato-ku, Tokyo 108-8255.

Please cut out and affix the mailing label below to the envelope and write "Notification Form" in
red on it to ensure that it goes to the proper section in the Tokyo Regional Immigration Bureau.

✂
〒108-8255
東京都港区港南 5-5-30
東京入国管理局
在留管理情報部門 届出受付担当 御中

✂
It is advisable to process the notification by post, but you can also submit the notification to
your local immigration office in person OR through the Immigration Bureau’s e-Notification
System*:
https://www.ens-immi.moj.go.jp/NB01/NBB01SAction.do?hdnGng=L2
(System operation environment: Internet Explorer 8 or higher)

If this is your first time to use the system, you need to register your personal information first.
* Please note the system requires you to enter information in Japanese in all fields except
the alphabetical name input field.

Thank you for your attention to this procedure.

Sincerely,

Interac Kanto North Co., Ltd.

ཧ⪃ᵝᘧ䠍䛾䠎䠄㞳⬺䠅
(Accepting organization: left the organization)
ά ື ᶵ 㛵 䛻 㛵 䛩 䜛 ᒆ ฟ
NOTIFICATION OF THE ACCEPTING ORGANIZATION
䐟䚷ᒆฟே Applicant
Ặ ྡ ᛶู ⏨䚷䞉䚷ዪ
Name Sex Male/Female
⏕ ᖺ ᭶ ᪥ ᖺ ᭶ ᪥ ᅜ ⡠ 䞉 ᆅ ᇦ
Date of Birth Year Month Day Nationality/Region
ఫ ᒃ ᆅ䛈
Address in Japan
ᅾ␃䜹䞊䝗␒ྕ
Residence card No.

䐠䚷ᒆฟ䛾஦⏤䠄άືᶵ㛵䛛䜙䛾㞳⬺䠅
Item of notification 䠄Left the organization䠅

㞳⬺䛧䛯ᖺ᭶᪥ ᖺ ᭶ ᪥
Date of left the organization Year Month Day

別紙参照
㞳⬺䛧䛯ᶵ㛵䛾ྡ⛠
Name of the organization

別紙参照
㞳⬺䛧䛯ᶵ㛵䛾ᡤᅾᆅ 䛈 㻔㟁ヰ㻌tel.䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷㻕䈜
Address of the organization

䐡䚷ᒆฟ௦⌮ே䠄ᮏே௨እ䛾⪅䛜ᒆ䛡ฟ䜛ሙྜ䛻グධ䠅 Representative or agent (in case of representative, agent or other)

Ặ ྡ ᮏ㻌㻌㻌ே㻌㻌㻌䛸㻌㻌㻌䛾㻌㻌㻌㛵㻌㻌㻌ಀ
Name Relationship with the applicant
ఫ ᡤ䛈 ᒆ㻌ฟ㻌ᖺ㻌᭶㻌᪥ ᖺ ᭶ ᪥
Address Date of notification Year Month Day

䐢䚷ᒆฟே䠄ᮏே䠅䛾⨫ྡ Signature of the applicant

ᖺ ᭶ ᪥
Year Month Day
䈜ᒆฟேཪ䛿ᒆฟ௦⌮ே䛾㐃⤡ඛ
Contact telephone number of the applicant, representative or agent
ヱᙜ䛩䜛䜒䛾䜢㑅䜣䛷䛟䛰䛥䛔䚹check one of the following boxes 䕕 ✔ ᒆฟே㻌applicant 䕕 ᒆฟ௦⌮ே representative or agent
㟁ヰ␒ྕ㻌Telephone No. ᦠᖏ㟁ヰ␒ྕ㻌Cellular phone No

䈜䚷ᮏ᭩୰䠈䈜䛾䛴䛔䛯㐃⤡ඛ䛻䛴䛔䛶䛿䠈ᒆฟෆᐜ䛾☜ㄆ䛾䛯䜑䠈㐃⤡䛥䛫䛶䛔䛯䛰䛟ሙྜ䛜䛒䜚䜎䛩䚹
 List of School(s) you just left (離脱)

School Name School Address School Phone #

ཧ⪃ᵝᘧ䠍䛾䠎䠄㞳⬺䠅
(Accepting organization: left the organization)
ά ື ᶵ 㛵 䛻 㛵 䛩 䜛 ᒆ ฟ sample
NOTIFICATION OF THE ACCEPTING ORGANIZATION
䐟䚷ᒆฟே Applicant
Ặ ྡ SMITH JOHN PAUL ᛶู ⏨䚷䞉䚷ዪ
Name Sex Male/Female
⏕ ᖺ ᭶ ᪥ 1985 ᖺ 01 ᭶ 01 ᪥ ᅜ ⡠ 䞉 ᆅ ᇦ British
Date of Birth Year Month Day Nationality/Region
ఫ ᒃ ᆅ䛈
Address in Japan
Room 201, ABC Apt., 1-2-3 XXX, YYYY City, ZZZZ Pref. 012-3456

ᅾ␃䜹䞊䝗␒ྕ F A 0 1 2 3 4 5 6 7 A B
Residence card No.

䐠䚷ᒆฟ䛾஦⏤䠄άືᶵ㛵䛛䜙䛾㞳⬺䠅
Item of notification 䠄Left the organization䠅

㞳⬺䛧䛯ᖺ᭶᪥ 2014 ᖺ 08 ᭶ 31 ᪥
Date of left the organization Year Month Day

別紙参照 (see the attached)

㞳⬺䛧䛯ᶵ㛵䛾ྡ⛠
Name of the organization

別紙参照 (see the attached)

㞳⬺䛧䛯ᶵ㛵䛾ᡤᅾᆅ 䛈 㻔㟁ヰ㻌tel.䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷㻕䈜
Address of the organization

䐡䚷ᒆฟ௦⌮ே䠄ᮏே௨እ䛾⪅䛜ᒆ䛡ฟ䜛ሙྜ䛻グධ䠅 Representative or agent (in case of representative, agent or other)

Ặ ྡ ᮏ㻌㻌㻌ே㻌㻌㻌䛸㻌㻌㻌䛾㻌㻌㻌㛵㻌㻌㻌ಀ
Name Relationship with the applicant
ఫ ᡤ䛈 ᒆ㻌ฟ㻌ᖺ㻌᭶㻌᪥ ᖺ ᭶ ᪥
Address Date of notification Year Month Day

䐢䚷ᒆฟே䠄ᮏே䠅䛾⨫ྡ Signature of the applicant

J o h n S mit h 2014 ᖺ
Year
09 ᭶
Month
05 ᪥
Day
䈜ᒆฟேཪ䛿ᒆฟ௦⌮ே䛾㐃⤡ඛ
Contact telephone number of the applicant, representative or agent
ヱᙜ䛩䜛䜒䛾䜢㑅䜣䛷䛟䛰䛥䛔䚹check one of the following boxes 䕕 ✔ ᒆฟே㻌applicant 䕕 ᒆฟ௦⌮ே representative or agent
㟁ヰ␒ྕ㻌Telephone No. n / a ᦠᖏ㟁ヰ␒ྕ㻌Cellular phone No 070 1234 5678

䈜䚷ᮏ᭩୰䠈䈜䛾䛴䛔䛯㐃⤡ඛ䛻䛴䛔䛶䛿䠈ᒆฟෆᐜ䛾☜ㄆ䛾䛯䜑䠈㐃⤡䛥䛫䛶䛔䛯䛰䛟ሙྜ䛜䛒䜚䜎䛩䚹
 Sample
List of School(s) you just left
/LVWRI6FKRROV\RXOHIW
ᩉᏮ 

6FKRRO1DPH 6FKRRO$GGUHVV 6FKRRO3KRQH

S-yama Elementary 2-18 S-yama, H-kawa-ku, N-yama City, S Prefecture

School  023
 456 7890

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School  023
 567 8901

M-gaoka Junior High 567 M-gaoka, H-kawa-ku, N-yama City, S Prefecture


School  023
 678 9012