別記第三十号様式䠄➨஧༑᮲㛵ಀ䠅
申請人等作成用 １ ᪥ᮏᅜᨻᗓἲົ┬
For applicant, part 1 Ministry of Justice,Government of Japan

ᅾ ␃ ㈨ ᱁ ኚ ᭦ チ ྍ ⏦ ㄳ ᭩
APPLICATION FOR CHANGE OF STATUS OF RESIDENCE
ධᅜ⟶⌮ᒁ㛗䚷䚷Ẋ䚷䚷 写 真
To the Director General of Regional Immigration Bureau

ฟධᅜ⟶⌮ཬ䜃㞴Ẹㄆᐃἲ➨䠎䠌᮲➨䠎㡯䛾つᐃ䛻ᇶ䛵䛝䠈ḟ䛾䛸䛚䜚ᅾ␃㈨᱁䛾ኚ᭦䜢⏦ㄳ䛧䜎䛩䚹 Photo
Pursuant to the provisions of Paragraph 2 of Article 20 of the Immigration Control and Refugee Recognition Act,
I hereby apply for a change of status of residence.

㻝䚷ᅜ䚷⡠䞉ᆅ䚷ᇦ 㻞䚷⏕ᖺ᭶᪥ ᖺ ᭶ ᪥
Nationality/Region Date of birth Year Month Day
Family name Given name
㻟䚷Ặ䚷ྡ
Name
㻠䚷ᛶ䚷ู ⏨ 䞉 ዪ 㻡䚷ฟ⏕ᆅ 㻢䚷㓄അ⪅䛾᭷↓ ᭷ 䞉 ↓
Sex Male/Female Place of birth Marital status Married / Single
㻣䚷⫋䚷ᴗ 㻤䚷ᮏᅜ䛻䛚䛡䜛ᒃఫᆅ
Occupation Home town/city
㻥䚷ఫᒃᆅ
Address in Japan
㟁ヰ␒ྕ ᦠᖏ㟁ヰ␒ྕ
Telephone No. Cellular phone No.
㻝㻜䚷᪑ๆ 㻔㻝㻕␒䚷ྕ 㻔㻞㻕᭷ຠᮇ㝈 ᖺ ᭶ ᪥
Passport Number Date of expiration Year Month Day
㻝㻝䚷⌧䛻᭷䛩䜛ᅾ␃㈨᱁ ᅾ␃ᮇ㛫
Status of residence Period of stay
㻌ᅾ␃ᮇ㛫䛾‶஢᪥ ᖺ ᭶ ᪥
Date of expiration Year Month Day
㻝㻞䚷ᅾ␃䜹䞊䝗␒ྕ
Residence card number
㻝㻟䚷ᕼᮃ䛩䜛ᅾ␃㈨᱁
Desired status of residence
㻌ᅾ␃ᮇ㛫 䠄ᑂᰝ䛾⤖ᯝ䛻䜘䛳䛶ᕼᮃ䛾ᮇ㛫䛸䛺䜙䛺䛔ሙྜ䛜䛒䜚䜎䛩䚹䠅
Period of stay ( It may not be as desired after examination.)
㻝㻠䚷ኚ᭦䛾⌮⏤
Reason for change of status of residence
㻝㻡䚷≢⨥䜢⌮⏤䛸䛩䜛ฎศ䜢ཷ䛡䛯䛣䛸䛾᭷↓㻌䠄᪥ᮏᅜእ䛻䛚䛡䜛䜒䛾䜢ྵ䜐䚹䠅 Criminal record (in Japan / overseas)
᭷ 䠄ලయⓗෆᐜ 䠅 䞉 ↓
Yes ( Detail: ) / No
㻝㻢䚷ᅾ᪥ぶ᪘䠄∗䞉ẕ䞉㓄അ⪅䞉Ꮚ䞉඗ᘵጜጒ䛺䛹䠅ཬ䜃ྠᒃ⪅
Family in Japan(Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents
ᅾ ␃ 䜹 䞊 䝗 ␒ ྕ
⥆䚷᯶ Ặ䚷ྡ ⏕ᖺ᭶᪥ ᅜ䚷⡠䞉ᆅ䚷ᇦ ྠ䚷ᒃ ໅ົඛ䞉㏻Ꮫඛ ≉ูỌఫ⪅ド᫂᭩␒ྕ
Residing with Residence card number
Relationship Name Date of birth Nationality/Region Place of employment/ school
applicant or not Special Permanent Resident Certificate number

䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䛿䛔䞉䛔䛔䛘
Yes / No
䈜 16䛻䛴䛔䛶䛿䠈グ㍕ḍ䛜୙㊊䛩䜛ሙྜ䛿ู⣬䛻グධ䛧䛶ῧ௜䛩䜛䛣䛸䚹䚷䛺䛚㻘䛂◊ಟ䛃䠈䛂ᢏ⬟ᐇ⩦䛃䛻ಀ䜛⏦ㄳ䛾ሙྜ䛿グ㍕୙せ䛷䛩䚹
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”.
䠄ὀ䠅㻌⿬㠃ཧ↷䛾ୖ䠈⏦ㄳ䛻ᚲせ䛺᭩㢮䜢సᡂ䛧䛶ୗ䛥䛔䚹䚷Note : Please fill in forms required for application. (See notes on reverse side.)
申請人等作成用 ２　　　N　（「高度専門職（１号イ・ロ）」・「高度専門職（２号）」・「研究」・「技術・人文知識・国際業務」・
「介護」・「技能」・「特定活動（研究活動等）」） （変更申請の場合のみ）
For applicant, part 2 N ("Highly Skilled Professional(i)(a/b)" / "Highly Skilled Professional(ii)"（only in cases of change of status） /
"Researcher" / "Engineer / Specialist in Humanities / International Services" / "Nursing Care" / "Skilled Labor"/ 在留期間更新・在留資格変更用
"Designated Activities(Researcher or IT engineer of a designated organization)") For extension or change of status
㻝㻣䚷໅ົඛ 䈜 㻔㻞㻕ཬ䜃㻔㻟㻕䛻䛴䛔䛶䛿䠈୺䛯䜛໅ົሙᡤ䛾ᡤᅾᆅཬ䜃㟁ヰ␒ྕ䜢グ㍕䛩䜛䛣䛸䚹
Place of employment For sub-items (2) and (3), give the address and telephone number of your principal place of employment.
㻔㻝㻕ྡ⛠ ᨭᗑ䞉஦ᴗᡤྡ
Name Name of branch
㻔㻞㻕ᡤᅾᆅ 㻔㻟㻕㟁ヰ␒ྕ
Address Telephone No.
㻝㻤䚷᭱⤊ᏛṔ䠄௓ㆤᴗົᚑ஦⪅䛾ሙྜ䛿ᮏ㑥䛾௓ㆤ⚟♴ኈ㣴ᡂ᪋タ䛻䛴䛔䛶グධ䠅
　Education (if you engage in activities of nursing care or teaching nursing care, fill in details about the certified care worker training facility in Japan)
䕕 ኱Ꮫ㝔㻌䠄༤ኈ䠅 䕕 ኱Ꮫ㝔㻌䠄ಟኈ䠅 䕕 ኱Ꮫ 䕕 ▷ᮇ኱Ꮫ 䕕 ᑓ㛛Ꮫᰯ
Doctor Master Bachelor Junior college College of technology
䕕 㧗➼Ꮫᰯ 䕕 ୰Ꮫᰯ 䕕 䛭䛾௚䠄 䠅
Senior high school Junior high school Others
㻔㻝㻕Ꮫᰯྡ 㻔㻞㻕༞ᴗᖺ᭶᪥ ᖺ ᭶ ᪥
Name of school Date of graduation Year Month Day

㻝㻥䚷ᑓᨷ䞉ᑓ㛛ศ㔝 Major field of study

䠄㻝㻤䛷኱Ꮫ㝔䠄༤ኈ䠅䡚▷ᮇ኱Ꮫ䛾ሙྜ䠅 (Check one of the followings when the answer to the question 18 is from doctor to junior college)
䕕 ἲᏛ 䕕 ⤒῭Ꮫ 䕕 ᨻ἞Ꮫ 䕕 ၟᏛ 䕕 ⤒ႠᏛ 䕕 ᩥᏛ
Law Economics Politics Commercial science Business administration Literature
䕕 ㄒᏛ 䕕 ♫఍Ꮫ 䕕 ṔྐᏛ 䕕 ᚰ⌮Ꮫ 䕕 ᩍ⫱Ꮫ 䕕 ⱁ⾡Ꮫ
Linguistics Sociology History Psychology Education Science of art
䕕 䛭䛾௚ேᩥ䞉♫఍⛉Ꮫ㻌䠄 䠅 䕕 ⌮Ꮫ 䕕 ໬Ꮫ 䕕 ᕤᏛ
Others(cultural / social science) Science Chemistry Engineering
䕕 ㎰Ꮫ 䕕 Ỉ⏘Ꮫ 䕕 ⸆Ꮫ 䕕 ་Ꮫ 䕕 ṑᏛ
Agriculture Fisheries Pharmacy Medicine Dentistry
䕕 䛭䛾௚⮬↛⛉Ꮫ㻌䠄 䠅 䕕 య⫱Ꮫ 䕕 ௓ㆤ⚟♴ 䕕 䛭䛾௚㻌䠄 䠅
Others(natural science) Sports science Nursing care and welfare Others
䠄㻝㻤䛷ᑓ㛛Ꮫᰯ䛾ሙྜ䠅
䕕 ᕤᴗ 䕕 ㎰ᴗ 䕕 ་⒪䞉⾨⏕ 䕕 ᩍ⫱䞉♫఍⚟♴ 䕕 ἲᚊ
Engineering Agriculture Medical services / Hygienics Education / Social welfare Law
䕕 ၟᴗᐇົ 䕕 ᭹㣭䞉ᐙᨻ 䕕 ᩥ໬䞉ᩍ㣴 䕕 ௓ㆤ⚟♴ 䕕 䛭䛾௚ 䠄 䠅
Practical commercial business Dress design / Home economics Culture / Education Nursing care and welfare Others
㻞㻜䚷᝟ሗฎ⌮ᢏ⾡⪅㈨᱁ཪ䛿ヨ㦂ྜ᱁䛾᭷↓㻌䠄᝟ሗฎ⌮ᴗົᚑ஦⪅䛾䜏グධ䠅 ᭷䞉↓
　Does the applicant have any qualifications for information processing or has he / she passed the certifying examination? 　Yes / No
　(when the applicant is engaged in information processing)
䠄㈨᱁ྡཪ䛿ヨ㦂ྡ䠅
（Name of the qualification or certifying examination）
㻞㻝䚷⫋䚷Ṕ 䚷Employment history
ධ♫ ㏥♫ ධ♫ ㏥♫
Date of joining the company Date of leaving the company ໅ົඛྡ⛠ Date of joining the company Date of leaving the company ໅ົඛྡ⛠
ᖺ ᭶ ᖺ ᭶ Place of employment ᖺ ᭶ ᖺ ᭶ Place of employment
Year Month Year Month Year Month Year Month

㻞㻞䚷௦⌮ே䠄ἲᐃ௦⌮ே䛻䜘䜛⏦ㄳ䛾ሙྜ䛻グධ䠅 Legal representative (in case of legal representative)

㻔㻝㻕Ặ䚷ྡ 㻔㻞㻕ᮏே䛸䛾㛵ಀ
Name Relationship with the applicant
㻔㻟㻕ఫ䚷ᡤ
Address
㟁ヰ␒ྕ ᦠᖏ㟁ヰ␒ྕ
Telephone No. Cellular Phone No.
௨ୖ䛾グ㍕ෆᐜ䛿஦ᐇ䛸┦㐪䛒䜚䜎䛫䜣䚹 I hereby declare that the statement given above is true and correct.
⏦ㄳே䠄ἲᐃ௦⌮ே䠅䛾⨫ྡ䠋⏦ㄳ᭩సᡂᖺ᭶᪥ Signature of the applicant (representative) / Date of filling in this form
ᖺ ᭶ ᪥
Year Month Day

ὀព Attention
⏦ㄳ᭩సᡂᚋ⏦ㄳ䜎䛷䛻グ㍕ෆᐜ䛻ኚ᭦䛜⏕䛨䛯ሙྜ䠈⏦ㄳே䠄ἲᐃ௦⌮ே䠅䛜ኚ᭦⟠ᡤ䜢ゞṇ䛧䠈⨫ྡ䛩䜛䛣䛸䚹
In cases where descriptions have changed after filling in this application form up until submission of this application, the applicant (representative)
must correct the part concerned and sign their name.
䈜䚷ྲྀḟ⪅
Agent or other authorized person
㻔㻝㻕Ặ䚷ྡ 㻔㻞㻕ఫ䚷ᡤ
Name Address
㻔㻟㻕ᡤᒓᶵ㛵➼䠄ぶ᪘➼䛻䛴䛔䛶䛿䠈ᮏே䛸䛾㛵ಀ䠅 㟁ヰ␒ྕ
Organization to which the agent belongs(in case of a relative, relationship with the applicant) Telephone No.