別記第三十号の二様式（第二十一条関係）
A frontal picture(40mm X
申請人等作成用 １ SAMPLE 日本国政府法務省
30mm) taken within the past
For applicant, part1 Ministry of Justice,Government of Japan
3 months. Including only the
applicant, hatless and on a
在 留 期 間 更 新 許 可 申 請 書 plain background. Write the
Please fill in “Hiroshima” APPLICATION FOR EXTENSION OF PERIOD OF STAY applicant's name on the
reverse side before you stick
入国管理局長　　殿　　 it here. 写 真
To the Director General of
HIROSHIMA Regional Immigration Bureau

出入国管理及び難民認定法第２１条第２項の規定に基づき，次のとおり在留期間の更新を申請します。 Photo
Pursuant 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 stay.
Birthday of your family member
1　国　籍・地　域 Nationality of your family member 2　生年月日 年 月 日
Nationality/Region Date of birth Year Month Day
Family name Given name
3　氏　名 Name of your family member
Name Please circle
Please circle
Birth place(Name of the country and the
4　性　別 男 ・ 女 5　出生地 6　配偶者の有無 有 ・ 無
city) of your family member Married / Single
Sex Male/Female Place of birth Marital status
7　職　業 Occupation of your family member
8　本国における居住地 Address (Name of the country and the city) of
Occupation Home town/city
your family in home country
9　住居地 Address in Japan
Address in Japan
電話番号 携帯電話番号 Mobile phone number in Japan
Telephone No. Passport number of your Cellular phone No.
10　旅券 (1)番　号 family member 年 family member's
(2)有効期限 Date of Expiration for your 月 passport
日
Passport Number Date of expiration Year Month Day
11　現に有する在留資格 在留期間
Depedent
Status of residence Period of stay
在留期間の満了日 年 月 日
Date of expiration Year Month Day
12　在留カード番号 Check from your family's residence card
Residence card number
13　希望する在留期間 （審査の結果によって希望の期間とならない場合があります。）
Desired length of extension
Desired length of extension of your family member ex.) 1 year
( It may not be as desired after examination.)

14　更新の理由
ex.) To live with my family who is studying at Hiroshima University
Reason for extension Please circle
15　犯罪を理由とする処分を受けたことの有無 （日本国外におけるものを含む。） Criminal record (in Japan / overseas)
有 （具体的内容 ） ・ 無
Yes ( Detail: ) / No
16　在日親族（父・母・配偶者・子・兄弟姉妹など）及び同居者
Family in Japan(Father, Mother, Spouse, Son, Daughter, Brother, Sister or others) or co-residents
在 留 カ ー ド 番 号
続　柄 Fill in all of your
氏　名family member in 生年月日
Japan 国　籍・地　域 同　居 勤務先・通学先 特別永住者証明書番号
Residing with Residence card number
Relationship Name Date of birth Nationality/Region Place of employment/ school
applicant or not Special Permanent Resident Certificate number

ex.) はい・いいえ
○○○○ ○○○○ ○○/○/○○ ○○○
Yes / No
Hiroshima University ○○○○○○○○
Spouse
はい・いいえ
Son ○○○○ ○○○○ ○○/○/○○ ○○○
Yes / No
○○○○○○○○
はい・いいえ
Yes / No
はい・いいえ
Yes / No
はい・いいえ
Yes / No
はい・いいえ
Yes / No
※ 16については，記載欄が不足する場合は別紙に記入して添付すること。　なお,「研修」，「技能実習」に係る申請の場合は記載不要です。
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”.
（注） 裏面参照の上，申請に必要な書類を作成して下さい。　Note : Please fill in forms required for application. (See notes on reverse side.)
申請人等作成用 ２　　　Ｒ　（「家族滞在」・「特定活動（研究活動等家族）」「特定活動（EPA家族）」）
For applicant, part 2 R （"Dependent" / "Dependent who lives with their supporter 在留期間更新・在留資格変更用
SAMPLE
whose status is Designated Activities (Researcher or IT engineer / Nurse and Certified Careworker under EPA)"） For extension or change of status

17　婚姻，出生又は縁組の届出先及び届出年月日
Authorities where marriage, birth or adoption was registered and date of registration
(1)日本国届出先
Japanese authorities
Fill either box (1) or (2) in
届出年月日 年 月 日 accord with information on
Date of registration Year Month Day the marriage / birth
certificate
(2)本国等届出先
Foreign authorities
届出年月日 年 月 日
Date of registration Year Month Day
18　滞在費支弁方法 Please check "Relatives"
Method of support
■ 親族負担 □ 外国からの送金 □ 身元保証人負担
Relatives Remittances from abroad Guarantor
□ その他 （ Please circle ）
Others
19　資格外活動の有無 有・無
Are you engaging in activities other than those permitted under the status of residence previously granted? Yes / No
有の場合は，(1)から(4)までの各欄を記入
Fill in (1) to (4) when your answer is "Yes".
(1)内　容 Fill in if the family member is engaging in some part-time job
Type of work
(2)名称 支店・事業所名
Name Name of branch
電話番号
Telephone No.
(3)週間稼働時間 時間 (4)報　酬 円 （ □ 月額　　
□ 日額 ）
Work time per week Hour(s) Salary Yen Monthly Daily
20　代理人（法定代理人による申請の場合に記入） Legal representative (in case of legal representative)
(1)氏　名 (2)本人との関係
Name Relationship with the applicant
(3)住　所
Address
電話番号 携帯電話番号
Telephone No. Cellular Phone No.

以上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.
申請人（法定代理人）の署名／申請書作成年月日 Signature of the applicant (legal representative) / Date of filling in this form

Signature of your family member and fill in the date of application 年 月 日

注意 Attention
申請書作成後申請までに記載内容に変更が生じた場合，申請人（法定代理人）が変更箇所を訂正し，署名すること。
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.
※　取次者 Agent or other authorized person
(1)氏　名 (2)住　所
Name Address
(3)所属機関等（親族等については，本人との関係） 電話番号
Organization to which the agent belongs (in case of a relative, relationship with the applicant) Telephone No.
扶養者等作成用 １　　　Ｒ　（「家族滞在」・「特定活動（研究活動等家族）」・「特定活動（EPA家族）」）
For supporter, part1 R（"Dependent" / "Dependent who lives with his or her supporter 在留期間更新・在留資格変更用
SAMPLE
whose status is Designated Activities (Researcher or IT engineer , Nurse and Certified Careworker under EPA)"） For extension or change of status

1　扶養している家族（申請人）の氏名及び在留カード番号
Name and residence card number of the foreigner to be supported (applicant)
(1)氏　名 Write the name of your family member
Name
(2)在留カード番号
Write the Residence card number of your family member
Residence card number
2　扶養者 Supporter
Fill in your own
(1)氏　　名
information
Name
(2)生年月日 年 月 日 (3)国　籍・地　域
Date of birth Year Month Day Nationality/Region
(4)在留カード番号
Residence card number
(5)在留資格 (6)在留期間
Status of residence Period of stay
(7)在留期間の満了日 年 月 日
Date of expiration Year Month Day
(8)申請人との関係 （続柄） Relationship with the applicant
□夫 □妻 □父 □母
Husband Wife Father Mother
□ 養父 □ 養母 □ その他 （ ）
Foster father Foster mother Others
Fill in the name of your
(9)勤務先名称 支店・事業所名
Hiroshima University school/graduate school
Place of employment Name of branch
(10)勤務先所在地 ※ (10)については，主たる勤務場所の所在地及び電話番号を記載すること。
Address For sub-items (10), give the address and telephone number of your principal place of employment.

Address of your school/graduate school

電話番号 Telephone number of your school/graduate school (support office)

以上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.
扶養者の署名及び押印／申請書作成年月日（印がない場合は押印省略可）
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.)
Put your signature here and fill in the 印 年 月 日
date of application Seal Year Month Day
注意 Attention
申請書作成後申請までに記載内容に変更が生じた場合，扶養者が変更箇所を訂正し，押印すること。
印がない場合は，変更箇所に署名すること。
In 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 correction.
In cases of not possessing a seal, sign the corrected part.