Ministry of Justice, Government of Japan

APPLICATION FOR RE-ENTRY PERMIT

To the Director General ofRegional Immigration Bureau

Pursuant to the provisions of Article 26, Paragraph 1 of the Immigration-Control and Refugee-Recognition Act, I hereby apply for re-entry permit.

1
Nationality

2
Date of birth

Family name

Year

Month
Given name

Day

3
Name in Chinese character

Name in English

4
Sex

Male/Female

5
Place of birth

6
Marital status

Married / Single

7
Occupation

8
Home town / city

9
Address in Japan

Telephone No.

Cellular Phone No.

10 (1)
Passport Number

(2)
Date of expiration

Year

Month

Day

11
Status of residence

Period of stay

Date of expiration

Year

Month

Day

12
Alien registration certificate number

13
Purpose of visit Expected destinations

Tourism

Business

Visit relatives

Study

Others

14 15
Expected date and port of departure

Year

Month

Day

(Air) Port

16
Expected date and port of re-entry

Year Single

Month

Day

(Air) Port

17
Which type of re-entry permit do you apply?

Multiple Criminal record (in Japan / overseas)

18
Yes (Detail:

) / No

19
Yes (Detail:

) / No Criminal action before confirming (in Japan / overseas)

20 21 (1)
Name

In case that you cannot obtain a passport, fill in the reason.

Proxy (in case of legal representative)

(2)
Relationship with the applicant

(3)
Address

Telephone No.

Cellular Phone No.

I hereby declare that the statement given above is true and correct. Signature of the applicant (legal representative) Date of filling in this form

Year

Month

Day

Attention
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 name.

22
Proxy, agent or other (in case of an agent, lawyer, administrative scrivener or other)

(1)
Name

(2)
Address

(3)
Organization to which the agent belongs (in case of a relative, relationship with the applicant)

Telephone No.