COVID-19 Vaccination Certificate for Overseas Travel Application Form

Dear: Mayor of the City of Nagoya MM/DD/YYYY

Katakana
(Person Vaccinated)

① Person
requesting Name
the
certificate Contact Phone * Write a number we can contact you during the day on weekdays.

Number ( － － )

Same as above (If there is a power of attorney, write the information of your agent.)

Katakana

Name

② Applicant
Relationship to Parent /
Husband Grandparent Other ( )
① Child
/ Wife / Grandchild

* Write a number we can contact you during the day on weekdays.

Contact Phone
Number ( － － )

* Be specific. Make sure to write the name of the country or region. Unacceptable
③ Travel Country / Region examples: Europe, Asia, etc. Acceptable examples: Italy, South Korea, etc.
Destination of Travel

・Make sure the following documents are ready.

① Copy of passport.
② Copy of vacci coupon (Make sure the vaccination coupon number is visible.) * If
you do not have a vaccination coupon, a copy of your My Number Card can be used
instead.
③ Copy of your certificate of vaccination for COVID-19 or record of vaccination for
COVID-19
④ Check List ④ Self-addressed envelope (make sure to attach a stamp and write the return
address)
⑤ Copy of a document verifying your name with your address.
* Only ready the following if they apply to you.
⑥ If the name on your passport is different (maiden name, different name,
alphabetized), include a copy of your ID.
⑦ If you are having an agent apply on your behalf, include a power of attorney with
your (the grantor's) signature.