APPLICATION FOR EXTENSION OF PERIOD OF STAY - …

1 For applicant, part1 Ministry of Justice,Government of JapanTo the Director general ofRegional Immigration BureauNationality/RegionDate of birthDayFamily nameGiven nameNameSexMale/FemalePlace of birthMarital statusOccupationHome town/cityAddress in japan Telephone phone No. Passport NumberDate of expirationDay Status of residencePeriod of stay Date of expirationDay Residence card number Desired length of EXTENSION ( It may not be as desired after examination.) Reason for extensionCriminal record (in japan / overseas)Yes ( Detail:) / No Family in japan (Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residentsNote : Please fill in forms required for APPLICATION . (See notes on reverse side.)Yes / NoYes / NoYes / NoYearMarried / SingleMonthAPPLICATION FOR EXTENSION OF PERIOD OF STAYYearYes / NoNationality/RegionYes / NoYes / NoResiding withapplicant or notPlace of employment/ schoolSpecial Permanent Resident Certificate numberResidence card number16 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 addition, take note that you are not required to fill in item 16 for applications pertaining to Trainee or Technical Intern Training.

2 MonthYearRelationshipNameDate of birthMonthPursuant 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 applicant, part 2 R "Dependent" / "Designated Activities(c)" / "Dependent who lives with their supporterwhose status is Designated Activities (Nurse and Certified Careworker under EPA)" For EXTENSION or change of statusAuthorities where marriage, birth or adoption was registered and date of registrationJapanese authoritiesDate of registrationDayForeign authoritiesDate of registration DayMethod of supportRelativesRemittances from abroadGuarantorOthersAre you engaging in activities other than those permitted under the status of residence previously granted? Fill in (1) to (4) when your answer is "Yes".Type of workNameName of branchTelephone time per weekHour(s)SalaryYenMonthlyDailyLegal representative (in case of legal representative)NameRelationship with the applicantAddressTelephone Phone 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 or other authorized personNameAddressTelephone to which the agent belongs (in case of a relative, relationship with the applicant)YearMonthYes / NoI hereby declare that the statement given above is true and of the applicant (legal representative) / Date of filling in this form For supporter, part1 R"Dependent" / "Designated Activities(c)" / "Dependent who lives with his or her supporterwhose status is Designated Activities (Nurse and Certified Careworker under EPA)"For EXTENSION or change of statusName and residence card number of the foreigner to be supported (applicant)

3 NameResidence card numberSupporterNameDate of birthDayNationality/RegionResidence card numberPeriod of stayDayRelationship with the applicantHusbandWifeFatherMotherFoster fatherFoster motherOthersPlace of employmentName of branchAddressFor sub-items (10), give the address and telephone number of your principal place of incomeYenI 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.)SealYearMonthDayAttentionIn 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 cases of not possessing a seal, sign the corrected of residenceDate of expirationMonthYearYearMonth