参考様式第１－１号

Reference Form 1-1

特 定 技 能 外 国 人 の 履 歴 書
CURRICULUM VITAE OF THE SPECIFIED SKILLED WORKER
①Name Roman
② Sex Male / Female
letters

Kanji
③ Date of birth DD/MM/YY
characters

④Nationality (country or ⑤ Reasonably

region) fluent languages

⑥Address in the country

of origin or country of （Tel:　　　　－　　　　－　　　　　）

residence

Year Month Most recent educational background/ main occupations

⑦Educational

background/ occupational

history

⑧Qualifications/

licenses

Year Month Status of residence Organization of affiliation, etc. Supervising organization

⑨If you have previously

resided in Japan with the

status of residence of

“Technical Intern Training”,

give your residence

history.

Notes.

Section ①. Write the name exactly as given in the passport in Roman letters, and if there is a name in kanji characters, give it

together with the Roman letters.

Section ⑤. Write the languages that the specified skilled worker is able to sufficiently understand (native language and others).

Section ⑨. Describe in detail the periods of residence in Japan with the status of residence of “Technical Intern Training”, the

implementing organization of the technical intern training, and the supervising organization (only in cases of supervising-

organization-type technical intern training).

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

　　　　Prepared on DD/MM/YYYY
Signature of the specified skilled worker　
参考様式第１－３号
Reference Form 1-3　
健 康 診 断 個 人 票
HEALTH CHECK REPORT
Date of health
Date of birth DD/MM/YYYY 　DD/MM/YYYY
Name check

Sex Male / female Age years

Work history Blood pressure　　　　　　　　（mmHg）

Anemia test Hemoglobin level （g/dℓ）

Red blood cell count

(10,000/mm³)

Past history Liver function GOT　（IU/ℓ）

test
GPT　（IU/ℓ）

γ - GTP　（IU/ℓ）

Subjective symptoms Blood lipid LDL cholesterol（mg/dℓ）

examination
HDL cholesterol（mg/dℓ）

Triglyceride（mg/dℓ）

Objective symptoms Blood glucose test 　（mg/dℓ）

Urinalysis Glucose

Protein
Height (cm)

Weight (kg) Electrocardiograph

examination

Other examinations

BMI Physician’s diagnosis

Waist circumference
(cm)

Right （　　　　）
Eyesight

Left （　　　　）

Right １ Normal　　２ Impaired

1,000Hz １ Normal　　２ Impaired
Remarks
Hearing

　 4,000Hz

Left １ Normal　　２ Impaired

1,000Hz １ Normal　　２ Impaired
 　 4,000Hz

Tuberculosis, Chest X-ray 　　Direct　　　　　Indirect

etc. examination 　　Taken　　　DD/MM/YYYY
No.
Film no. Findings:

Notes.

1. The BMI is calculated using the following formula.　　　　　　　 BMI = 　Body weight(㎏)
　　　　　　　　　　　　　　　　　　　　　　　　　　Height(m)²
2. In the column of “Eyesight”, write the number outside the parentheses ( ) if it has not been corrected,
and inside the parentheses ( ) if it has been corrected.
3. If abnormal findings are found in the “Chest X-ray examination” section, conduct a sputum
examination and confirm there is no active tuberculosis.
4. In the “Physician’s diagnosis” section, fill in the physician’s diagnosis such as no abnormality, detailed
examination required, medical examination required, etc.
5. If a disease is currently being treated, describe the medical condition which needs to be noted
medically, such as the current medical history and the name of the disease in the “Physician’s
diagnosis” section. In addition, in such case, describe all the prescribed drugs in the remarks section.

The person mentioned above is not infected with the infectious diseases shown above and there are no
health risks with regard to conducting stable and continuous employment activities in Japan.

(Physician) Signature
参考様式第１－３号（別紙）
Reference Form 1-3 (Attachment)

受診者の申告書

Declaration by Medical Checkup Examinee

私は，通院歴，入院歴，手術歴，投薬歴の全てを医師に申告
した上で，医師の診断を受けました。

I hereby declare that I informed a doctor of my full medical

history, including hospital visits, hospitalization, surgeries, and

medication. After providing this information, I was examined by

the doctor.

作 成 年 月 日　　　　　年　　　月　　　日
Prepared on DD /MM /YYYY

申請人の署名
Signature of the applicant
 　　　　　　　　　　　　　　　　
　　　　　　　

参考様式第１－５号
Reference Form 1-5　　　　　　　　　　　　　　　　　　　　　　　　　　

特 定 技 能 雇 用 契 約 書
EMPLOYMENT CONTRACT FOR SPECIFIED SKILLED WORKERS

Organization of affiliation of the specified skilled worker ______________________________________

(hereinafter referred to as “organization”)

Specified skilled worker (including specified skilled worker candidates) __________________________

(hereinafter referred to as “specified skilled worker”)

This Employment Contract is hereby entered into in accordance with the contents described in the
attached Written Employment Conditions.

This Employment Contract shall come into effect upon the specified skilled worker entering Japan with
the status of residence of “Specified Skilled Worker (i)” or “Specified Skilled Worker (ii)”, and starting to
engage in the activities for the work requiring the skills provided for in an ordinance of the Ministry of
Justice as stipulated by the Minister of Justice for a specified industrial field.

The period of the Employment Contract (beginning and end of the Employment Contract) stated in the
Written Employment Conditions must be changed in accordance with the actual date of entry if the date
of entry of the specified skilled worker differs from the scheduled date of entry.

The Employment Contract shall be terminated at the time of the period of the Employment Contract
expiring without being renewed, or if the specified skilled worker has forfeited the status of residence for
any reason.

The Employment Contract and Written Employment Conditions shall be prepared in duplicate, and one
copy shall be retained by each party.

　　　　　　　　　Entered into on DD/MM/YYYY

Organization　　　　　　　　　　　　　Seal Specified skilled worker

(Name of the organization of affiliation of the Signature of the specified skilled worker)
specified skilled worker, and name, title and seal of
its representative)
参考様式第１－６号
Reference Form 1-6

雇 用 条 件 書
WRITTEN EMPLOYMENT CONDITIONS

DD/MM/YYYY　　

To: 　　　　　　　　　　　　　　　

Name of the organization of affiliation of the specified skilled worker: 　　　　　　　　　　　　　　　　　

Address: __________________________________________________________________________________

Tel. no.: ___________________________________________________________________________________

Representative’s name and title: _____________________________________________________________ Seal

I．Period of the employment contract

　1. Period of the employment contract

　　（From: (DD/MM/YYY) to (DD/MM/YYYY)　　Scheduled date of entry: DD/MM/YYYY）

　2. Renewal of contract

□　The contract shall be automatically renewed　　　　　□　The contract may be renewed　　　

□　The contract is not renewable

　 　*If the contract may be renewed, the renewal of the contract shall be determined by the following criteria.

□　Volume of work to be done at the time the term of contract expires　　　　□　Employee’s work record and work attitude　　

□　Employee’s capability to execute their tasks

□　Business performance of the company　　　　　　　　□　State of progress of the work done by the employee　　　

□　Other (　　　　　　　　　　　　　　　　　　　)

II．Place of employment

□ Direct employment (fill in below) □ Dispatch employment (fill in the separate “Employment Conditions Statement”)

Name of office 　　　　　　　　　　　　　　　　　

Address　　　　　　　　　　　　　　　　　　　　

Contact information　　　　　　　　　　　　　　　

III．Contents of work to be engaged in:

　1. Field ( )

　2. Work category ( )

IV．Working hours, etc.

　１．Start and finish times

　(1) Start time: ( : ) Finish time: ( : ) (Number of prescribed working hours in one day: ( ) hours ( ) minutes

　(2) 【If the following systems apply to the worker】

　　□　Irregular labor system： irregular labor system unit ( )

　　　* If an irregular labor system is adopted, attach a copy of the yearly calendar in a language the specified skilled worker can fully understand, and a copy of the

agreement on the irregular labor system submitted to the Labor Standards Inspection Office.
　　□　Work shift system using a combination of the following working hours

　　　Start time ( : ) Finishing time ( : ); Day applied ( 　　　 ); prescribed working hours for one day ( ) hours ( ) mins

Start time ( : ) Finishing time ( : ); Day applied (　　　　); prescribed working hours for one day ( ) hours ( ) mins

Start time ( : ) Finishing time ( : ); Day applied (　　　　); prescribed working hours for one day ( ) hours ( ) mins

　2. Break time　　( minutes)

　3. No. of prescribed working hours ① Week ( ) hours ( ) mins　② Month ( ) hours ( ) mins　③ Year ( ) hours ( ) mins

　4. No. of prescribed working days ① Week ( ) days　② Month ( ) days　③ Year ( ) days

　5. Overtime work　　　□　Yes　　　　□　No

　　　○ Details are stipulated in Article ( ), Article ( ) and Article ( ) of the Rules of Employment.

V．Days off

　1. Regular days off: Every ( ), national holidays, others ( ) (total number of annual days off: ( ) days

　2. Additional days off: ( ) days per week/month, others ( )

○ Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.

VI．Leave

　1. Annual paid leave Those working continuously for six months or more →　(　　　) days

　　　　　　　　　　Those working continuously for up to six months（□ Yes □ No）→ After a lapse of ( ) months and ( ) days

2. Other leave　　　Paid (　　　　　　　　　) Unpaid ( )

　3. Leave for temporary return home: If the specified skilled worker wishes to return home temporarily, he or she must be given necessary days off

within the scope of the abovementioned 1 and 2.

　○ Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.

VII．Wages

1. Basic pay　　　□　Monthly wage (　　　　　yen)　　□　Daily wage (　　　　yen)　　□　Hourly wage (　　　　　yen)

　* Details given in the attachment.

2. Various allowances (excluding additional pay rate for overtime)

　　　　　(　　　　　　　allowance，　　　　　　　allowance，　　　　　　　allowance)

　* Details given in the attachment.

　3. Additional pay rate for overtime, holiday work or night work

　　(1) Overtime work:　Legal overtime 60 hours or less a month ( ) %　

　　　　　　　　　　　Legal overtime over 60 hours a month (　　　 )%

　　　　　　　　　　　Fixed overtime (　　　　　　) %

　　(2) Holiday work　　　　　Legal holiday work ( ) %，　　Non-legal holiday work ( ) %　

　　(3) Night work　　　　　( )%

　4. Closing day of payroll　　　□ ( ) of every month; ( ) of every month

　5. Pay day　　　□ ( ) of every month; ( ) of every month

　[Link] of wage payment　　□　Bank transfer　　　　□　Payment in yen (cash)

　7. Deduction from wages in accordance with labor-management agreement　　□　No　　　　□　Yes

　　* Details given in the attachment.

　8. Wage raise　　　　　　□　Yes (Timing，amount, etc.　　　　　　　　　　　　　　　　　　　　　)　□　No

　9. Bonus　　　　　 　□　Yes (Timing amount, etc.　　　　　　　　　　　　　　　　　　　　　　)　□　No

　10．Retirement allowance　　　　　□　Yes (Timing, amount, etc. ) 　　　　　　　　　　　□　No

　11. Leave allowance　　　　□　Yes (rate　　　　　　　　　　　　　　　　　　　　　　　　　　　　　)

VIII．Items concerning retirement

　1. Procedure for retirement for personal reasons (Notification should be made to the president or the factory foreman, etc. no less than ( ) days

before retirement)

　2. Reasons and procedure for the dismissal

　　　In cases of dismissal, the specified skilled worker shall be dismissed through being given 30 days’ advance notice or at least 30 days of the

average wage only when there are unavoidable reasons for the dismissal. In cases of dismissal based on a cause attributable to the fault of the

specified skilled worker, there is the possibility of immediate dismissal without giving advance notice or the average wage being paid on approval

being obtained from the Director of the Labor Standards Office Concerned.

Details are stipulated in Article ( ), Article ( ) of the Rules of Employment.

IX．Others

　１．Joining social insurance / employment insurance (□　Employees’ pension insurance，□　Health insurance，□　Employment

insurance

□ Industrial accident insurance　□ National pension)　

□　National health insurance　□　Others ( 　　　 )

２．Health check at the time of hiring: Month ( ) Year ( )

　３．First regular health check: Month ( ) Year ( ) (every ( ) afterwards)

４．If the specified skilled worker is unable to pay for the travel expenses to return to his or her home country after the termination of this

contract, the organization shall pay for the travel expenses and take necessary measures to ensure smooth departure.

Recipient（signature）
参考様式１－６　別紙

Reference Form 1-6　Attachment

　　　　　　　　　　　　　　　　　　　　　　　　　 　　　　　　　　　　　
賃 金 の 支 払
PAYMENT OF WAGES

１．Basic Wages

　　□　Monthly wage (　　　yen) □　Daily wage (　　　　yen) □　Hourly wage (　　　　yen)

* Amount per hour in cases of monthly or daily wages (　　　　　　yen)

* Amount per month in cases of daily or hourly wages (　　　　　　yen)

２．Amount and calculation method for various allowances (excluding the additional pay rate for overtime)

(a) (　　　　　allowance　　　　　yen; Calculation method　　　　　　　　　　)

(b) (　　　　　allowance　　　　　yen; Calculation method　　　　　　　　　　)

(c) (　　　　　allowance　　　　　yen; Calculation method　　　　　　　　　　)

(d) (　　　　　allowance　　　　　yen; Calculation method　　　　　　　　　　)

３．Estimated payment per month (1+2)　　　　　 　　　approx.　　　　　　　　　yen (total)

４．Items to be deducted when paying wages　　　

(a) Tax (approx. yen)

(b) Social insurance (approx. yen)

(c) Employment insurance (approx. yen)

(d) Food (approx. yen)

(e) Housing (approx. yen)

(f) Others (utility costs) (approx. yen)

(approx. yen)

(approx. yen)

(approx. yen)

(approx. yen)

(approx. yen)

Amount to be deducted　　approx.　　　　　　　　　yen (total)

　　
5．Take-home pay (3 - 4)　　　　　　　　　　　approx.　　　　　　　　　yen (total)

* Provided there is no absence from work, etc. and excluding additional pay, etc. for overtime work.
参考様式第１－７号
Reference Form No. 1-7　　　　　　　　　　　　　　　　　　　　　　　　　　　　

事 前 ガ イ ダ ン ス の 確 認 書
CONFIRMATION OF ADVANCE GUIDANCE

1. Matters concerning the content of the work I am engaged in, the amount of remuneration, and other
working conditions

2. Contents of the activities I am permitted to engage in while in Japan

3. Matters concerning the procedures for when I enter Japan

4. Neither I nor my spouse, lineal relative or relative cohabiting with me or any other person who has a
close relationship with me in terms of a social life are, in connection with the activities I am to engage
in while in Japan based on an employment contract for specified skilled workers, paying a deposit, or
having my money or other property otherwise being managed regardless of the reason therefor, and I
have not entered into a contract nor am I expected to enter into a contract that stipulates penalties with
regard to non-performance of the employment contract for specified skilled workers or a contract
which otherwise expects the transfer of undue money or other property.

5. If I am paying expenses to an organization in my own country or another country in connection with an

application for an employment contract for specified skilled workers, or for preparation for the
activities of specified skilled worker (i), I fully understand the amount and breakdown of the expenses,
and the organization must have entered into an agreement with me about these expenses.

6. I am not being made to pay directly or indirectly for the expenses required for my support.

7. The organization of affiliation of specified skilled workers, etc. must pick me up from the seaport or
airport at which I intend to enter Japan.

8. I am being given support pertaining to securing appropriate housing for me.

9. There is a system in place so I can make a request for advice or to make a complaint about my work
life, general living or social life.

From: Time ( : ) to ( : ) on DD/MM/YYYY

From: Time ( : ) to ( : ) on DD/MM/YYYY
From: Time ( : ) to ( : ) on DD/MM/YYYY
Name of the organization of affiliation of specified skilled workers (or registered support
organization)

　　　　　　　　　　　　　　　　　　　　　　　

Name of the explaining party

　　　　　　　　　　　　　　　　(Seal)

I have received an explanation from the above person and fully understood the contents.
In addition, with regard to 4, neither I, my spouse nor any related person has entered into a contract
concerning the payment of a deposit or penalties, nor will I enter into such contract in the future.

Signature of the specified skilled worker ________________________ DD/MM/YYYY

 参考様式第１－８号
Reference Form 1-8　

支払費用の同意書及び明細書
CONSENT FOR PAYMENT OF EXPENSES AND WRITTEN STATEMENT OF EXPENSES

Specified skilled worker paying expenses

Name:
Sex:
Date of birth: 　　　　　　DD/MM/YYYY
Nationality / region:

Expenses collected by the organization in a foreign country

Name of organization
Expense item Date of collection Amount
collecting expenses

1 DD/MM/YYYY
　　( yen)

2 DD/MM/YYYY
　　　( yen)

3 DD/MM/YYYY 　( yen)

4 DD/MM/YYYY
　( yen)

5 DD/MM/YY'YY 　　　　( yen)

Total　　　　
( yen)
Notes.

1. The organization in a foreign country is not restricted to any particular organization, and means an organization which

mediates applications for employment contracts for specified skilled workers or is involved in the preparations for the

activities.

2. Give the amount in the local currency or USD, and write the amount converted into Japanese yen in parentheses.

3. For the expense items, give the expense item as indicated to the applicant.

I paid the abovementioned amounts to the organization in a foreign country for the mediation of an
application for the employment contract for a specified skilled worker or the preparations for the
activities related to the status of residence of “Specified Skilled Worker” having fully understood the
breakdown of the expenses.
In addition, I have not paid any expenses other than the expenses listed above.
Prepared on DD/MM/YYYY

Signature of the specified skilled worker

 __________________________________
参考様式第１－１０号
Reference Form 1-10

技能移転に係る申告書
WRITTEN DECLARATION ON THE TRANSFER OF SKILLS

Declarant

Name:

Sex: Male / Female

Date of birth:

Nationality / region:

I hereby declare the following matters.

Details

I am aware that the purpose of the technical intern training program in Japan is to promote
international cooperation by transferring skills, etc. to developing regions etc.
I have acquired the skills, etc. pertaining to ________________ that would be difficult to acquire, etc.
in my home country of ___________________, and have completed the technical intern training.
Therefore, I would like to work on transferring the skills, technology or knowledge pertaining to
____________________ which I acquired in Japan, or for which I increased or attained proficiency, to
my home country upon my return to my home country in future,

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

Date: (DD/MM/YYYY)

Signature of the declarant ____________________

参考様式第１－１６号
Reference Form 1-16　　　　　　　　　　　　　　　　　　　　　　　　　　

雇用の経緯に係る説明書
Explanation of Employment Background

特定技能外国人　　　　　　　　　　　　　　　との間で特定技能雇用契約を締結するに当たっての雇用
の経緯は以下のとおりです。
Regarding the conclusion of the employment contract with specified skilled worker _________________,
the employment background is as follows.

１　職業紹介事業者（国内）
Employment placement business provider (in Japan)

１ あっせんの有無
□　有　　　　　　　　　　　□　無
Use of an employment
Yes No
placement service i

２ 許可・届出受理番号
（受理受付年月日）
Acceptance No. for －　－　　　　　　（ 　 　年　　 月　　 日）
approval and notification －　－　　　　　　（　DD　　　/MM　　　 /YYYY　　）
(Date of acceptance and
receipt)

３ 職業紹介事業者の区分 □　有料職業紹介事業者
Category of the □ Fee-charging employment placement business provider
employment placement □　無料職業紹介事業者
business provider □ Free employment placement business provider

４ 職業紹介事業者の氏名
Name of the employment
placement business
provider

５ 職業紹介事業者の住所 〒　　　 －　
（電話番号）
Address of the （電話番号　　　－　　　　－　　　　）
employment placement （Telephone number　　　－　　　－　　　　）
business provider
(Telephone number)

６ 職業紹介事業者へ支払っ 求職者 額 （　　　　　　　　　円）　　　（

 （申請人） Amount yen）

Job seeker 名目 　　　　　　　　　　　　　　として

(the applicant) Description For payment of

た費用 求人者 額 （　　　　　　　　　円）　　　（

Expenses paid to the （特定技能所属機 Amount yen）

employment placement 関）

business provider Job offeror

(the organization of 名目 　　　　　　　　　　　　　　として
affiliation of the Description For payment of
specified skilled
worker)

（注意）

(Notes)

１ １欄で無にチェックを付した場合には，２以下の欄の記載は不要とする。

If you ticked “No” in section 1, you do not need to fill out sections below section 2.

２ ２から５欄までは，厚生労働省職業安定局ホームページの「人材サービス総合サイト」を活用し，当該職業紹介事業者についての該当する

情報を記入すること。

Fill in the relevant information for the applicable employment placement business provider in sections 2, 3, 4, and 5, using the

“Comprehensive Human Resource Services Website” which is operated by the Employment Security Bureau of the Ministry of Health,

Labour and Welfare.

３ ６欄は，求職者及び求人者が職業紹介事業者に支払った額及び名目について記載すること。なお，求職者が日本円以外で費用を支払った場

合は，当該通貨で支払った額及び日本円に換算した額を記載すること。

Fill in the amount and description of the money paid by the job seeker and job offeror to the employment placement business provider in

section 6. Please note that if the job seeker paid the expense in a currency other than yen, you must state the amount paid in the local

currency, as well as that amount converted to yen.

４ 職業紹介事業者との間で交わした契約書があれば，その写しを添付すること。

If you have a written contract exchanged with the employment placement business provider, please attach a copy of it.

２　取次機関（国外）（１で有にチェックを付した場合のみ記載）
Agent organization (outside Japan) (Only those who ticked “Yes” in section 1 above need to fill in the form
below)
１ 取次ぎの有無
□　有　　　　　　　　　　　□　無
Use of service provided by
Yes No
the agent organization
２ 氏名又は名称
Name of the agent
organization
３ 所在国
 Country where the agent
organization is located
４ 所在地
Address of the agent （電話番号　　　－　　　　－　　　　）
organization （Telephone number　　　－　　　　－　　　）

求職者 額 （　　　　　　　　　円）　　　（

（申請人） Amount yen）

Job seeker 名目 　　　　　　　　　　　　　　として

(the applicant) Description For payment of

５ 取次機関へ支払った費用 求人者 　　　　　　（

額
Expenses paid to the （特定技能所属機 円）
Amount
agent organization 関） （　　　　　　　　　yen）
Job offeror
(the organization of
名目 　　　　　　　　　　　　　　として
affiliation of the
Description For payment of
specified skilled
worker)
（注意）

(Notes)

１ 取次機関とは，職業紹介事業者が求人者に求職者のあっせんを行うに際し，当該職業紹介事業主に対し求職者等に係る情報の取次ぎを行う

者をいう。

The agent organization means the party that acts as the agent handling the job seeker’s information for the applicable employment

placement business provider, in the case where the job offeror uses the employment placement service provided by the employment

placement business provider to recruit the job seeker.

２ １欄で無にチェックを付した場合には，２以下の欄の記載は不要とする。

If you ticked “No” in section 1, you do not need to fill out sections below section 2.

３ ５欄は，求職者及び求人者が取次機関に支払った額及び名目について記載すること。なお，求職者及び求人者が日本円以外で費用を支払っ

た場合は，当該通貨で支払った額及び日本円に換算した額を記載すること。

Fill in the amount and description of the money paid by the job seeker and job offeror to the agency organization in section 5. Please note

that if the job seeker and job offeror paid their expenses in a currency other than yen, you must state the amount paid in the local currency,

as well as that amount converted to yen.

４ 取次機関との間で交わした契約書があれば，その写しを添付すること。

If you have a written contract exchanged with the agency organization, please attach a copy of it.

以上の内容について相違ありません。
I hereby declare that the statement given above is true and correct.
 作成年月日：　　　　年　　　月　　　日
Prepared on DD /MM /YYYY

特定技能所属機関の氏名又は名称　

Name of the organization of 　　　 　　　　　　　　　　　　　　　　　　　　　

affiliation of the specified skilled worker

作 成 責 任 者 の 氏 名 及 び 役 職　　　　　　　　　　　　　　　　　　　　　㊞

Name and title of the person 　　　　　　　　　　　　　　　　　　　　　　Seal

responsible for preparing this document

申 請 人 の 署 名 　 　 　 　

Signature of the applicant 　 　 　

参考様式第１－２４号　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
Reference Form 1-24

つうさんざいりゅうきかん かかるせいやくしょ
通 算 在 留 期間に係る 誓 約 書

Pledge for Total Period of Stay

 とくてい ぎ の う いちごう ざいりゅう し か く へ ん こ う き ょ か ま た とくてい ぎ の う いちごう か か る

「 特定技能１号」 へ の 在留資格変更許可又は 「 特定技能１号」 に 係る

ざいりゅう き か ん こ う し ん き ょ か う け る あ た っ て か き じ こ う せいやく

在留期間更新許可を受けるに当たって，下記の事項について誓約します。
In connection with receiving permission to change the status of residence
to “Specified Skilled Worker (i),” or to extend the period of stay for
“Specified Skilled Worker (i),” I hereby pledge that I shall comply with the
following matter.

とくてい ぎ の う いちごう つうさんざいりゅう き か ん ごねん た っ し た じてん とくてい ぎ の う

　「 特定技能１号」での 通算 在 留 期間が ５年に 達した時点で「 特定技能
いちごう かつどう しゅうりょう とくてい ぎ の う ごう いこう ばあい
１号」 の 活動を 終 了 し ， 「 特定技能２ 号」 へ の 移行を す る 場合等 を
の ぞ い て きこく
除いて帰国します。
I shall terminate activities concerning “Specified Skilled Worker (i)” at
the time when the total period of stay under the status of residence of
“Specified Skilled Worker (i)” reaches five (5) years, and shall return to my
country, excluding the case of changing my status of residence to “Specified
Skilled Worker (ii).”

　　　　　　　　　　　　　　　　　　　　　　　　年　　　月　　　日
　　　　　　　　　　　　　　　　　　　　　　　　DD/MM/YYYY

　　　　　　　　　　　　　　　　　申請人署名　　　　　　　　　　　
　　　　　　　　 　　　　　　　Signature of the applicant　　

参考様式第５－７号
Reference Form 5-7

報酬支払証明書
Proof of Payment of Remuneration
　　　月分（　 月　 日から　 月　 日　分）の報酬について，以下のとおり支払いました。

The remuneration for the month of (from DD/MM to DD/MM) was paid as follows.

１　対象労働者
The worker for whom the payment was made
① 氏名（ローマ字） ② 性　　　別 男　・　女
Name (Roman letters) Sex Male / Female

③ 生　年　月　日 ④ 国籍・地域
Date of birth Nationality/region

⑤ 在留カード番号
Residence Card No.

２　報酬
Remuneration
① 報酬総額
円
Total amount of
Yen
remuneration
② 現金支給額 円
Amount paid in cash Yen
③ 支給日 年　　　　月　　　　日
Payment date DD/MM/YYYY
（注意）

(Notes)

１　上記２①は，控除前の報酬総額を記載すること。

The total amount of remuneration before deductions must be stated in ① of section 2 above.

２　上記２②は，控除後の手取り報酬額を記載すること。

The amount of take-home pay after deductions must be stated in ② of section 2 above.

上記の記載内容は，事実と相違ありません。
I hereby declare that the statement given above is true and correct.

年　　　月　　　日
DD / MM / YYYY

特定技能所属機関の氏名又は名称　　　　　　　　　　　　　　　　　　

Name of the organization of affiliation of the specified skilled worker

作成責任者　役職・氏名　　　　　　　　　　　　　　　　　　　　　㊞
 Name and title of the person responsible for preparing this document Seal

給与支給者　役職・氏名　　　　　　　　　　　　　　　　　　　　　㊞

Name and title of the salary payer 　　　　　　　　　　　　　　　　　　Seal

報酬について，雇用条件書どおりの報酬額であることを確認し十分に理解した上で，上記の内容どお
り支給を受けました。
I have checked and fully understood that the amount of remuneration is just the same as what is
stated in the Written Employment Conditions, and have received the above payment of remuneration.

年　　　　月　　　　日
DD / MM / YYYY

特定技能外国人の署名　　　　　　　　　　　　　　　　　　　　　　　

Signature of the specified skilled worker

参考様式第５－８号
Reference Form 5-8　　　　　　　　　　　　　　　　　　　　　　　　　　　　
 生 活 オ リ エ ン テ ー シ ョ ン の 確 認 書
Confirmation of Orientation for Life in Japan

１　私の日本での生活一般に関する事項
General matters concerning my life in Japan
２　私が出入国管理及び難民認定法第１９条の１６その他の法令の規定により履行しなければならない
又は履行すべき国又は地方公共団体の機関に対する届出その他の手続に関する事項
Matters concerning notifications and other procedures which I must or should make to national or
local government agencies, pursuant to the provision of Article 19-16 of Immigration Control and
Refugee Recognition Act, and other laws and regulations.
３　私が把握しておくべき，特定技能所属機関又は当該特定技能所属機関から契約により私の支援の実
施の委託を受けた者において相談又は苦情の申出に対応することとされている者の連絡先及びこれら
の相談又は苦情の申出をすべき国又は地方公共団体の機関の連絡先
The contact information of the organization of affiliation of the specified skilled worker, the contact
information of the person who is in charge of handling my consultations and complaints and belongs to
the party that is entrusted with providing me with support pursuant to the contract with the organization
of affiliation of specified skilled workers, and the contact information of the national or local
government agency where I should consult or make a complaint about the aforementioned
organization/party if necessary, which I should understand.
４　私が十分に理解することができる言語により医療を受けることができる医療機関に関する事項
Matters concerning medical institutions where I can receive medical treatment in a language in which
I am reasonably fluent.
５　防災及び防犯に関する事項並びに急病その他の緊急時における対応に必要な事項
Matters concerning disaster prevention and crime prevention, and matters necessary for taking
action at a time of sudden illness or other emergency.
６　出入国又は労働に関する法令の規定に違反していることを知ったときの対応方法その他私の法的保
護に必要な事項
What to do if I notice a violation of provisions of laws and regulations regarding immigration or labor,
and other matters necessary for my legal protection.

について，
Date of explanation:

　　　　年　　月　　日　　時　　分から　　時　　分まで
From: Time ( : ) to ( : ) on DD/MM/YYYY
　　　　　　　　　年　　月　　日　　時　　分から　　時　　分まで
From: Time ( : ) to ( : ) on DD/MM/YYYY
　　　　　　　　　年　　月　　日　　時　　分から　　時　　分まで
From: Time ( : ) to ( : ) on DD/MM/YYYY
 特定技能所属機関（又は登録支援機関）の氏名又は名称
Name of the organization of affiliation of the specified skilled worker (or
registered support organization)

　　　　　　　　　　　　　　　　　　　　　　　

説明者の氏名
Name of the explaining party

　　　　　　　　　　　　　　　　㊞

Seal

から説明を受け，内容を十分に理解しました。
I have received an explanation from the above person and fully understood the contents.

特定技能外国人の署名　　　　　　　　　　　　　　　　　　　　　年　　　月　　　日　

Signature of the specified skilled worker DD/MM/YYYY