ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAEAFAGAHAIAJ
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別記第二十九号の四様式（第十九条の二関係）
日本国政府法務省
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Ministry of Justice,Government of Japan
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資格外活動許可申請書
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APPLICATION FOR PERMISSION TO ENGAGE IN ACTIVITY OTHER THAN THAT
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PERMITTED UNDER THE STATUS OF RESIDENCE PREVIOUSLY GRANTED
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出入国在留管理局長　　殿
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To the Director General of the
Regional Immigration Services Bureau
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出入国管理及び難民認定法第１９条第２項の規定に基づき，次のとおり資格外活動の許可を申請します。
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Pursuant to the provisions of Paragraph 2 of Article 19 of the Immigration Control and Refugee Recognition Act, I hereby
apply for permission to engage in activities other than those permitted under the status of residence previously granted.
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※本申請書により，上陸許可に引き続き資格外活動許可申請を行うことができるのは，上陸の許可により
「留学」の在留資格を決定された場合（３月の在留期間を決定された場合を除く。）に限られます。
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Persons, who are able to file for this application following acquisition of landing permission, are limited to those who
have been granted the status of residence of “Student” based on the landing permission (excluding those who have
been granted a period of stay of three (3) months).
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1国　籍・地　域
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Nationality / Region
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2生年月日年月日
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Date of Birth
Year
Month
Day
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3氏　名　
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Name (in English)
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4性　別男・女
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Sex
Male
/
Female
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申請人の署名／申請書作成年月日
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Signature of the applicant / Date of filling in this form
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年月日
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Year
Month
Day
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