別記第二十号様式（第二十条関係）
申請人等作成用 1
For applicant, part 1
日本国政府法務省
Ministry of Justice,Government of Japan
在 留 資 格 変 更 許 可 申 請 書
APPLICATION FOR CHANGE OF STATUS OF RESIDENCE
法 務 大 臣 殿
To the Minister of Justice
出入国管理及び難民認定法第20条第2項の規定に基づき、次のとおり在留資格の変更を申請します。
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.
Nationality/Region
Date of birth
年
Year
月
Month
日
Day
Name
Family name
Given name
Sex
Male
Female
Place of birth
Marital status
Married
Single
Occupation
Home town/city
Address in Japan
Telephone No.
Cellular phone No.
Passport
Number
年
Year
月
Month
日
Day
Status of residence
Period of stay
年
Year
月
Month
日
Day
Residence card number
Desired status of residence
Period of stay
（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。）
(It may not be as desired after examination.)
Reason for change of status of residence
Criminal record (in Japan / overseas) ※Including dispositions due to traffic violations, etc.
Yes（Detail:
/ No
Family in Japan (father, mother, spouse, children, siblings, grandparents, uncle, aunt and others) and anyone you currently reside with
Yes (If yes, please fill in your family members in Japan and anyone you currently reside with in the following columns.)
/ No
| 続柄 Relationship |
氏名 Name |
生年月日 Date of birth |
国籍・地域 Nationality/Region |
同居の有無 Residing with applicant or not |
勤務先名称・通学先名称 Place of employment/school |
在留カード番号 特別永住者証明書番号 Residence card number Special Permanent Resident Certificate number |
|---|---|---|---|---|---|---|
|
|
※ 3について，有効な旅券を所持する場合は，旅券の身分事項ページのとおりに記載してください。
Regarding item 3, if you possess your valid passport, please fill in your name as shown in the passport.
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，「在日親族」のみ記載してください。
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 only required to fill in your family members in Japan 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.)
（注）申請書に事実に反する記載をしたことが判明した場合には，不利益な取扱いを受けることがあります。
Note : In case of to be found that you have misrepresented the facts in an application, you will be unfavorably treated in the process.