For applicant, part1 Ministry of Justice,Government of Japan

APPLICATION FOR EXTENSION OF PERIOD OF STAY

To the Director General of Regional Immigration Bureau

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.

Nationality/Region Date of birth Year Month Day

Family name Given name

Name

Sex Male/Female Place of birth Marital status Married / Single

Occupation Home town/city

Address in Japan

Telephone No. Cellular phone No.

Passport Number Date of expiration Year Month Day

Status of residence Period of stay

Date of expiration Year Month Day

Residence card number

Desired length of extension ( It may not be as desired after examination.)

Reason for extension

Criminal record (in Japan / overseas)

Yes ( Detail: ) / No

Family in Japan(Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents

Residing with Residence card number

Relationship Name Date of birth Nationality/Region Place of employment/ school
applicant or not Special Permanent Resident Certificate number

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No
16
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”.
Note : Please fill in forms required for application. (See notes on reverse side.)
For applicant, part 2 R "Dependent" / "Designated Activities(c)" / "Dependent who lives with their supporter
whose status is Designated Activities (Nurse and Certified Careworker under EPA)" For extension or change of status

Authorities where marriage, birth or adoption was registered and date of registration

Japanese authorities

Date of registration Year Month Day

Foreign authorities

Date of registration Year Month Day

Method of support

Relatives Remittances from abroad Guarantor

Others

Are you engaging in activities other than those permitted under the status of residence previously granted? Yes / No

Fill in (1) to (4) when your answer is "Yes".

Type of work

Name Name of branch

Telephone No.

Work time per week Hour(s) Salary Yen Monthly Daily

Legal representative (in case of legal representative)

Name Relationship with the applicant

Address

Telephone No. Cellular Phone No.

I hereby declare that the statement given above is true and correct.
Signature of the applicant (legal representative) / Date of filling in this form

Year Month Day

Attention

In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant (legal
representative) must correct the part concerned and sign their name.
Agent or other authorized person

Name Address

Organization to which the agent belongs (in case of a relative, relationship with the applicant) Telephone No.
For supporter, part1 R "Dependent" / "Designated Activities(c)" / "Dependent who lives with his or her supporter
whose status is Designated Activities (Nurse and Certified Careworker under EPA)" For extension or change of status

Name and residence card number of the foreigner to be supported (applicant)

Name

Residence card number

Supporter

Name

Date of birth Year Month Day Nationality/Region

Residence card number

Status of residence Period of stay

Date of expiration Year Month Day

Relationship with the applicant

Husband Wife Father Mother

Foster father Foster mother Others

Place of employment Name of branch

Address For sub-items (10), give the address and telephone number of your principal place of employment.

Telephone

Annual income Yen

I hereby declare that the statement given above is true and correct.

Signature and seal of supporter or guarantor Date of filling in this form (In cases of not possessing a seal, it it possible to omit it.)

Seal Year Month Day

Attention

In cases where descriptions have changed after filling in this application form up until submission of this application, the supporter or guarantor
must correct the part concerned and press its seal on the correction.
In cases of not possessing a seal, sign the corrected part.