(Note)Partner's profession/occupation (orthat of parents, if applicant is a minor}:

Guarantor or reference in Japan(Please provf* •Us of the [Link] or the person to be visited In Japan)
Name Tel.
----------------------- ---------
Address
----------------------------------
Date of birth~(b,...ay~ll=tMo~.~iiti ~))=!V,=.ea-,~> Sex; Male D Femc1le D
Relationship to applicant_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Profession oroccupation and position_______________________
Nationality and immigration status_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inviter in Japan(Please write 'sameanbove' ifthe inviting person and the guarantor are the same)
Name_______________________ Tel.'----------

Adclres~-------------------------------
Date ofblrth Sex: Male D F'emale D
--=1oa,,_y)...,.t=c~-=-,-nth-,-,)""/f'(,.,.ear--,--)
Relationship to applicant_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Profession or occupation and position _______________________
Nationallty [Link] status_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Note)Remarks/Special circumstances, if any_____________________
Have you ever:
• been convicted of a crime or offence in any country? YesO Noc0
• been sentenced to Imprisonment for 1 year or more In any couhtry?(Note 2') Yes □ No□
• been depprted or removed from Japan 9r-any country fur overstayingyo1.1r vis.a ·or violating
any law or regulation? Y,s □ No □
• been convicted and sentenced for a drug offence ih any country in Violation of law
concerning narc<>~. ml!riJuana, opium, stimu~nts or psycho,tropic substances?(Note 2) YesD N<r□
• engaged in prostitution, or In the Intermediation or solicitation of a prostitute fot other
JM!.rsons, or In th.e provision ofa place for prostitution, or any other activity directly
connected to prostitution? • • YesO No□
• committed trafficking In persons or lntjted or [Link] ano~r to commit sych an offence? Yes □ No□
(Note,2) Please tick "'Yes• lfyou have [Link] [Link]:e, [Link] ifthe sentence was suspended.
If you answered "Yes" to any of the above questions, [Link] provide relevant details.

•1 h!lreb>' dec;[Link] that the statement given ~ve ls trµeand:co~ I un4ffllilnd [Link] lmmlgrat!Qn c$tatll5 and period of ~tay to
be granted are dedded by the·Japanese·lmmlgration .authoritieS lipbri my arrival. I understand that .possession of a visa does not
entitle the bearer to enter Japan upon arrival at port ofentry If he or she Is founcflnadmiSsible;"
•1 hereby consent to the provision of my persOl\lll ln~mation (by an cl(:aedited travel a.9ent, within. Its aipacity of representing
my visa appllc;atlon) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the
0

Japanese einbassy/consulat~eneral; when such payment ls necessary;"

Signature of applicant
Date of application_.,,(oay
......);""(M,.,.o_n.,,.th"')lfY"".ear--.).-- --------------
(Notellt [Link] mandatory to complete tl1ese items.

Any personal Information filled In this application fonn aswl!ll as additional petsonal Information submitted forthe visa
appikatlon (here(nafter referred to as "Retalnf!d Perspnal Information?) will be handled appropriately by the Ministry of Foreign
Affi!lrs of Japan ([Link]$!! overse;is ~bltshmtints) In accordance Y,iiththe Acton~ Pr9_t~ion of Pe~nal
Information (Act No. 57 of2003, hereinafter, ?the Act?).,Retatned Personal Information will only be used to the extent necessa,y
for the purpose of processing the visa application (lndudlng providing petsonal Information to the,transportatlon·company
whid! 'YQ\I are going to t,av,~ with, 9f the alternative transpqi:tatlon .c~mpany which YQ~ are going to travel with,due:to
[Link] drcumstanceslilrtnnigratl<!n conm>I, [Link] cooperation andfor Other pt1rposes In co,npllance wlth Artlde'69
of the Act.
 VISA APPLICATION FORM TO ENTER JAPAN

(Paste photo here)

45mmX35nvn
Offldal .use only
or li'!X 1.4ln

Sumatne (jtS shown in pas$port)

------------------------
Given and [Link] (as shown in passport)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Other name (indudlng any other names you are or have been known by)

Date of birth-...:=mn=.,.....= :Place of birth

.. (Pay)/{MonffiJ/(Year) --_""'(city"""
......
) -----,,cs=~.,..te-or"'"P,...ro--.~-.-.-l-----,c,...~---...,.-,>,----_-
Sex: Male D F-e'male D Marital status: Single D Married D Widowed D Divorced D
N'atlonallfy or citizenship _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Former and/or other nationalities or citizenships _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ID No. issued to you byyourgovemment.__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Passport type: Diplomatic D Official O Ordinary D Other D Passport No._ _ _ _ _ __
Place of issue~._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date of issue
-=(Oay,-.,,,)/(""'Mo,...ntli"""""')l=r;ve-a..,..r)
Issuing at.1thonty_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date of expiry • • • •
(Oay)/(Month)J(Vear)
Certificate of Ellgiplllty No._ _ _ __
Purpose of visit [Link]/Status of residence_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Intended length of stay in Japan_______ Date ohrrival in Japan_ _ _ _ _ _ _ _ __
P-ort of entry into Japan Name of ship or airline_ _ _ _ _ _ _ _ __
Names and addresses of hotels or persons with whom applicant intends to stay
Name. Tel.- - - - - - - -
--------------------
Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Dates ctnd duratkm of previous stays in Japan_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Yout curreot residential address (If you have li'AQre tban one address, please list them all)

Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Tel ._ _ _ _ _ _ _ Mobile No._ _ _ _ _ __
E~all_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Current profession or occupation and position_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Name and address of employer
Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Tel._ _ _ _ _ _ __

Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
 Letter of Guarantee
(Year) ffllf (Mouth) (Day)

To: ( ~ofJipm in ~

Visa AmJHggt
(Ibel)lll:Ile~ be'M'iilrn in1b&,U,tinalpha!>et• i t ~ (;J11Jis.1!er~ When~ ~tWC! (rllllJle l!PJlligmls. fill in
1hmpreseu1Bli.-e's'Slatus below, andatlaeh a list ofallapplicam.) •

Full1111II£([Link]): ~ ' ~li:la va~

4JMald .EIFermle)
(Numberofaddlti!mal IIJ!)licanls.{ifapplicable) :
[Link]: ~-; I I / ~
(Yest) )(Mooth) / (Day)
N ~ flu~
Ocmpatioo· ~. ~ A ~

lguanmteetheibillgsreprdlngCbe~appllcanf1entryimoJapan:

L FJipmes far 11w. applbnt'omy lnhplm

2. Return tnvel eq,emes;
3. O;mpllani:ewitb Japanele laws and , . ...dons

I hereby declare tbattbe:llbcM.•is tn1e.

Gumm
Full Ill!II£: (Ns) •0iffir. .~~ .I)ji'IIIIPI

DateQfbirth: IQU) I JI /'JS (Age:. 51 )

(Year) I (Month) /(Day)
Address: T 9'i - fX!'l-1

T~.11Urd1er: ( 060 ) ~ - 'l,-b?Jl) (Extlll'lsm )

FAX number: ( )
Occupation/Nameof~ ~'1,9 Cari~
Relationsbipwith1he0visaapplidml(s) da1t31-<ter

[Fillin1be•~C91111!Ctin~ when the~OJg!lllizatipn is·mmding·tbe~]

Fullname:
[Link]. ( ) (EYlfnsim )
FAXtljllllber. ( )
~

(Note)
♦ When a ~~ is e:xlmling an invitlllion, fill u the mme ofthe coq,any/organization 1111 wdl a,)'8111' title.
 !Yea() -Wl,ll' (Monlh) ll {Pio:) 7
fJ..

Travel Itinerary

'ibetravel itinerarymlhe visa applicanl(s) isa., fuilo,ws:

Date Activitv Plan Contact Accommodation

[Link] ~ "'-'tall~ ¥
'lltfj)jJ (~1) Itl:.-L!p l!itl. ifilj\ffo, 'II, Atf,_&"8 ft.\(~. 01CIJJjtl Uliw...,. }Jt~&

Fe,~t o.l"d [Link] ill

'"'''I (Cbt 1') ~\-4 Jc_,t,[Link]'!! : fisql'o ~(;md

~ll!QOrt -

111,Jt~ l9itJ) r~ 14 kr : ,\fgr!io'yo""' ,oi,c! ki"llb;Jt

·1QViJ111, (tli1 'I) ijSJ 9· a~~

¢1,(1/1 tili1;) ~re. ftllWI j()fl'-Y\
 List of Visa Applicants

► This form must be c o ~ l>y the inviting person/guarantor when two or more Bl'[Link] intend to apply fQr a visa at the same time.
► Pl~ write the Daine of the principal appliamt in.1"11i{a#dif£tltd,l!Dd Letter [Link].
► The name must be written in the Latin alphabet as •it appears on theit passport.
► If the inviting penon [Link] guarantor are the same, write "same as above" in the ''relatic)nshlp I!) the inviting persQD/guaranror!' field.
Fulhiame : ( Male • ~ )
Date ofbirth : I~ I 1 / ~P (Age: t,1 )
.(Year)/ (Month) I (D11y)
Nationality : ~('lilQ
Occupation : «tal ,ltlile ~
Relationship to the invitiflg person : ~ Cwio1:11o<)

guarantor : ~ , ~ ~
Full Iiati:!e : ~ - l ~ ~°"re, ~ ~ - Female)
Date [Link] : ..-:i- / O'.I / 11 ( Age: 11- )
:(Year) I (Month) I (Day)
Natjonajity : f<liPI~ •
Occupation : J ~
Relationship to the inviting person : °'i'<l (foil)
guarantor : 0e,l\il), ~r' ~
Full natne: ( Male • Female,)
D~ pfbirth: t I ( A;ge: ,)
(Year)/ .(Month}/ (Day)
Nationl!lity :
Occupation :
Relationship to the inviting person :
guarantor:
Full name: ( Male • Female )
Date [Link] : ( Age:
(Yeat) / (M()hth) / (Day)
Nation'ality :
Occupation :
Relationship to the inviting~. :
guarantor:
Full name.: ( Male • Female )
Date ofbirth : I I ( Age: )
(Year) / (Month) I (Dat)
Nationality :
Occupation :
Relationship to the inviting person :
guarantor:
Full name: ( Male • Female )
Date of birth : I ( Age: )
(Year)/ ~onth) / (Day)
Nationality :
Occupation :
Relationship to the invi~g pe,:son :
~or:
 Letteroflnvbtion

•
To; ( ~ o f ~_ _ _ __
llplnin __

ImidngPerson
(}Vbenanmwillg}'.bl!allDia~are1besime._ywmaywrile''Saml,•~•-)
Full:Name: ~vi ,~ai»~ ~1.t11a!-\
.Mkea;: 'i' ~ -lKi'i-'!1 Q~~i £\Jllit~-~~ 1~[Link] 4(j\&111e l,-g i\atl,f [Link]~ il01

[_Fi]l:inh~<XUlietinfi:umlniMlell1he~()(gm,m11l~.~1heinvilalicnl
FullNmre:
Telqhn:N\mier:( ) ([Link] )
~ ·

Vi..aApplioint
(Ibenillllen:[Link]~•it111JmS<11hi9tlerplSl!p(Xt When1herearetwoa-m.:re~.fillin1be
~ve;s~bdow,IDillllaclialistofiil~)
[Link]): .0,.n~ , tlil~ V,1~ {l:MaleMFEmlle)
~of~l~(d)1Jpi~): I )
Dlleofliltt 1 / ll_()
\q~ / (Ai,:; 01 )
(Ytltr)/~/(Da:y)
~ ; fikpiRO
(mpilim· (/(ol tNte ~

1bepmpol!leofimtingdieabmie~s)kasMlnw:
(lfhspu:·bdowm~ usea~~.Qf)Jl{l!:l't>~afullexpj!i[Jldim.)
(1) ~ofmvil!Un.
• . 10 foi/itt, 1\-1~ mo\;Mtr ~·~ .S'OI) io u!Sil, ~1"1 ~
~~, OV16 ,o ~ quo.i\ibi -hwie- ¾nei:;fer·
(2) ~ b ~ ~ 1 b e ~ t > t 1 : i s ~ i n ~ ) ,2...u,. 'L
i !lill:I~~ ""1 ~• ~ ' {'llilii(oW>itci V<\\al)lli\fD ~ ""(JP!'I, l'UfW• -..14ot>• [Link])e- ru. . . ,._ -'-'-
1,1H11ift11'1 ,'/,/rlV•-

iK ~r~\.!~ .• ~(llb ~ flit'

.•. ½D S'[Link].S· ThlS ~ ~ a111 OffUri~~~.10~ . ~~"(~ ~ ,
(li-,t J1iNe IIOl;.sa., ~ 6l,lw .for kwnl 111omlu'- 0,,,;11:, ~rlb(, I,... lo .. ~ OIi ~ lt;it lQ - S ~
• ,~.,ll\lo\tr"'3 .i,W,,I ~. eip,,~ ~ flql ~ l w • u,jquc (l&ltln. oil t1ie ~ - •
(3) Rdlnn;bip wjdi via~$}
~ '~~rdo -~•l'9c'Ol!lf!<l • ~
~ 'uslllri ~ ~ - r>,i'd

(Nde)
♦ Wlma~i$-~iln~fill-11he~oflbe~~•wdl•[Link].