※This form is only for Kanagawa prefecture.

You can’t use this form for other prefectures.

Please fill in the red box. No seal is needed.

Do not use erasable pens.
Write the date you
come to apply.

神奈川 太郎

Kanagawa Taro

2000 １ １

Japan Kanagawa

2-4-1201, Kaigandori, Naka Ward,

Yokohama City, Kanagawa Prefecture

ＴＲ１２３４５６７

Applying for permanent residency

The United States of America

2-4-1201, Kaigandori, Naka Ward,

Yokohama City, Kanagawa Prefecture

090－1234－5678
※This form is only for Kanagawa prefecture.
You can’t use this form for other prefectures.

※Don’t
write
anything
here.

※Don’t
write
anything
here.

Please fill in the red box. No seal is needed.

Do not use erasable pens.
Write the date you
come to apply.

Same as written in your passport

※Leave here blank if you don’t have your name in Kanji

Same as written in your passport

2000 １ １

Leave here blank

Japan
Write your address in Kanagawa prefecture.
※If you live outside Japan, write your foreign address.
Write the number on your latest passport.
※Leave here blank if you don’t have a passport.
Write the type of your visa.
（Ex. : permanent residency/work visa/residence permit etc.）

Write the country you are submitting the certificate to.

Write your current address

or the address you are staying at in Japan temporarily

Write a Japanese phone number where we can reach you.

※Don’t write anything here.

別記様式第１号
作成者

犯罪経歴証明書発給申請書
（ Application Form for Certificate of Criminal Record）

神奈川県警察本部長 殿 検査者

私は、下記の目的のため、私の指紋を添えて犯罪経歴証明書を申請します。
I apply for a certificate of criminal record for the reason stated below.
I'll submit a digital record of my fingerprints or a sheet with my fingerprints on it.
注 意： 楷書（ 欧文は活字体 ）で記入して下さい 。
N O T E： Please fill out blanks in BLOCK LETTERS.

申 請 日(西暦) (year) (month) (day)

Date of application 年 月 日
氏 名 (姓) （名）
漢 字
（戸籍の氏名のつづり）
(Family) (First) (Middle)
ﾛｰﾏ字
Name
生年月日 (year) (month) (day) 性別
男 (M)・女 (F)
Date of birth 年 月 日 Sex
国 籍 等 本籍地 都道
Nationality Domicile 府県
現 住 所
Current address
旅券番号
Passport number

申請目的
Reason for application
提出先国
Country(area) to which
the certificate will be
submitted

連絡先(Contact address & Telephone number)

住 所
Address
電話番号
Telephone number
（注）恩赦を受けている場合は、特赦状、復権状等を添えて申し出てください。
Note: If a pardon has been granted, please produce a writ concerning the pardon.
Pick Up (year) (month) (day) (Signature)
受 領 年 月 日 氏名
交付