参考様式第１－１７号

Reference Form 1-17

１ 号 特 定 技 能 外 国 人 支 援 計 画 書
Support Plan for Specified Skilled Worker (i)

Prepared: DD MM YYYY
Ⅰ Subject of support

BODHIPAKSHALAGE NAYANAJITH MADUSANKA RANASINGHE

1. Name 2. Sex Male/ Female
(No of other potential specified skilled workers: )

２５ ０３ １９９２
3. Date of birth 4. Nationality / Region Sri Lanka
DD MM YYYY

KABUSHIKIGAISYA FONSU
1. Name with furigana
株式会社フォンス
Ⅱ Organization of affiliation of specified skilled workers (i)

Postal code 389 － 0102

2. Address 長野県北佐久郡軽井沢町軽井沢 1075-47
（Telephone no. － － ）
Postal code －
3 Location of office providing
support
（Telephone no. － － ）
(fill in when different to 2)

Name with
Support manager furigana
Title

Has neutrality of support been secured?

4. Details of the structure in
place to perform the support
work
No. of specified skilled workers
(i) providing support
No. of persons:
The person responsible for support and the person in charge of support do not have the authority
to give the recipient of support orders (for example, employees in a different department from the
recipient of support) or even where they are in different departments, they are not in a position
where they have the authority to give the recipient of support orders.

No. of support staff No. of persons:

Yes No
 2. Date of DD/MM/YYYY 3. Scheduled date of start DD/MM/YYYY
1. Registration number Registration １９登－０００４９１
registration １１/０６/２０１９ of support work ０１/０７/２０２３

KABUSHIKIGAISYA SHIJISUKAI
4. Name with furigana
株式会社シジスカイ

Postal code 101 － 0032

5. Address 東京都千代田区岩本町 ３－４－５ 第１東ビル８０１号室
（Telephone number ０３－６８０３－０６１２）
HASEGAWA RINA
In the case of a
Ⅲ Registered support organization
corporation

6. Name of the
representative with
furigana 長谷川 莉夏

Postal code －
7. Address of the office SAME
providing support
（Telephone number － － ）
SUJAN SANDAMAL
Name with
Support manager furigana
Title Support Person
SUJAN SANDAMAL

Has appropriateness of support been secured?

No. of specified skilled workers
8. Details of the structure in No. of persons: ０
(i) providing support The person responsible for support is not the spouse of an officer of the organization with which
place to perform the support the specified skilled worker is affiliated, is not within a second degree of relationship by blood, is
not a person who has a close relationship in social life with an officer of the organization with
work which the specified skilled worker is affiliated, and has not been in the last five years an officer or
an employee of the organization with which the specified skilled worker is affiliated.
- There exists no reason of refusal for the registration as a registered support organization of the
person responsible for support and the person in charge of support.

No. of persons: ０
No. of support staff Yes No
 Support staff or implementing staff if the support is to be outsourced
Scheduled implementation Outsourced Implementation method
Contents of support Name Address
of support Yes No (Check all the applicable boxes)
(Title) (Only when outsourced)
a. Matters concerning the content of Postal code 〒101－0032 □ In person
work to be engaged in, the amount of SUJAN SANDAMAL □ Video call equipment
Yes / No 東京都千代田区岩本町 ３－４－５
remuneration, and other working （Support Person） □ Other（ ）
第１東ビル８０１号室
conditions
b. Contents of activities that can be
engaged in while in Japan (In cases
where the
details for
c. Matters concerning procedures for (In cases where the
each case of
entering Japan details of each case of (In cases where the details of each case of (In cases where the details of each case of
support is
support is different, support is different, please explain below) support is different, please explain below)
different,
please explain below)
d. Prohibition of the collection of a please
deposit or conclusion of a contract explain
A. Contents of information provision, etc.

which stipulates penalties with regard below)

to non-performance of the contract
Ⅳ Contents of support

1. Provision of advance guidance

e. If expenses are to be paid to an

organization in a foreign country in
relation to preparations for entry into
Japan, the specified skilled worker (i)
must fully understand the amount of
the expenses and a breakdown before ü Yes（ ）
paying the expenses □ No（ ）
f. The foreign national must not be
made to pay any expenses necessary
for the support
g. Contents of support relating to
picking the specified skilled worker (i)
up at the time of entry into Japan

h. Contents of support relating to

securing housing

i. Contents relating to handling of

consultations for advice and
complaints
j. Name and contact information of the
support staff of the organization of
affiliation of the specified skilled
worker (i)
Free description
(Other details)
Ⅳ Contents of support

1. Provision of advance guidance

B. Language that the support is to be given in Language: Sinhala, English （where there is interpretation provided by someone other than the person in charge of support) Name and position of interpreter

C. Scheduled hours of support Total number of hours: ３

Support staff or implementing staff if the support is to be outsourced

2. Pick up and drop off at time of

Outsourced Implementation method

Contents of support Scheduled implementation Name Address
Yes No (Check all the applicable boxes)
(Title) (Only when outsourced)
entry or departure

a. Pick up at the airport or seaport of arrival ü Yes（ ） Postal code 〒101－0032 □ Airport or seaport of arrival
and transfer to the organization of affiliation SUJAN SANDAMAL (NARITA Airport)
Yes / No 東京都千代田区岩本町 ３－４－５
of the specified skilled worker (i) or to the □ No（ ） （Support Person） □ Method of pick-up（ ）
第１東ビル８０１号室
accommodation
b. Drop off at the scheduled airport or ü Yes（ ） Postal code 〒101－0032 □ Scheduled airport or seaport of departure
seaport of departure and assistance with the SUJAN SANDAMAL ( Airport/Undecided)
Yes / No 東京都千代田区岩本町 ３－４－５
departure procedures until entering the □ No（ ） （Support Person） □ Method of pick-up（ ）
第１東ビル８０１号室
security check line
Free description □ Yes Postal code －
(Other details) Yes / No
□ No
3. Support for suitable accommodation and contracts for general living

Support staff or implementing staff if the support is to be outsourced

Scheduled implementation Outsourced
Contents of support Name Address Method of implementation of support
of support Yes No
(Title) (Only when outsourced)
a. Provision on information on real Postal code 〒101－0032
A. Support related to securing suitable accommodation

estate agencies and rental properties,

and where necessary, accompanying
the specified skilled worker (i) to help
with the procedures to secure housing,
and assist in finding a residence. In
addition, if a guarantor is required at ü Yes（ ） SUJAN SANDAMAL
the time of the conclusion of the rental Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
contract, and there is no suitable 第１東ビル８０１号室
guarantor, either become a guarantor
for the specified skilled worker (i) or
secure an available rental debt
guarantor who will act as the
guarantor of the specified skilled
workers (i), and act as the emergency
b. Personally become the tenant and Postal code 〒101－0032
enter into a rental agreement, and ü Yes（ ） SUJAN SANDAMAL
Yes / No 東京都千代田区岩本町 ３－４－５
offer the residence to the specified □ No（ ） （Support Person）
第１東ビル８０１号室
skilled worker (i) with his/her consent
Postal code 〒101－0032
c. With the agreement of the specific ü Yes（ ） SUJAN SANDAMAL
skilled worker (i) provide company Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
housing, etc. as a residence 第１東ビル８０１号室
 Free description □ Yes Postal code －
(Other details) Yes / No
□ No
Whether housing has already been secured at the time of submission of the application for permission to change the status of residence (or application of
□
issuance of a certificate of eligibility)
Whether housing is to be secured after submission of the application for permission to change the status of residence (or application of issuance of a certificate
□
d. Summary of the residence for which of eligibility)
information is to be provided or the Size of room (Total no. of co-habitants: )
housing to be provided as residence
2
(including cases where planned for Secure at least 7.5 m of space per
provision) ü Size of sleeping space
person

□ Secure sleeping space of at least 4.5 m2 in space per person

Support staff or implementing staff if the support is to be outsourced

Outsourced Implementation method
Contents of support Scheduled implementation Name Address
Yes No (Check all the applicable boxes)
(Title) (Only when outsourced)
B. Support related to contracts necessary for general living

Postal code 〒101－0032 □ Provision of information on procedures

a. Assist with procedures to open a
ü Yes（ ） SUJAN SANDAMAL □ Where necessary, accompany the
deposit account or savings account at Yes / No 東京都千代田区岩本町 ３－４－５
（Support Person） specified skilled worker (i) to assist with
a bank or other financial institution □ No（ ） 第１東ビル８０１号室
the procedures
□ Others ( )
Postal code 〒101－0032 □ Provision of information on procedures

b. Assist with procedures to enter into ü Yes（ ） SUJAN SANDAMAL □ Where necessary, accompany the
Yes / No 東京都千代田区岩本町 ３－４－５
a contract for use of a mobile phone （Support Person） specified skilled worker (i) to assist with
□ No（ ） 第１東ビル８０１号室
the procedures
□ Others ( )
Postal code 〒101－0032 □ Provision of information on procedures

c. Assist with procedures for lifelines ü Yes（ ） SUJAN SANDAMAL □ Where necessary, accompany the
Yes / No 東京都千代田区岩本町 ３－４－５
such as electricity, water, gas （Support Person） specified skilled worker (i) to assist with
□ No（ ） 第１東ビル８０１号室
the procedures
□ Others ( )
Free description □ Yes Postal code －
(Other details) Yes / No
□ No
Support staff or implementing staff if the support is to be outsourced
Outsourced Implementation method
Contents of support Scheduled implementation Name Address
Yes No (Check all the applicable boxes)
(Title) (Only when outsourced)
a. Matters concerning general living in
Japan

SUJAN SANDAMAL
（Support Person）

Postal code 〒101 － 0032

4. Implementation of guidance on general living

東京都千代田区岩本町 ３－４－５
A. Contents of information provision

第１東ビル８０１号室
Yes / No

ü Yes（ ）
□ No（ ）
 b. Matters concerning notification to
an organization of the national
government or local government
SUJAN SANDAMAL
which the specified skilled worker (i)
（Support Person）
has to make pursuant to the provisions
of laws and regulations and matters
relating to other procedures, and □ In person
Postal code 〒101 － 0032
4. Implementation of guidance on general living

where necessary, accompanying the □ Video phone calls, viewing of DVDs, etc.
specified skilled worker (i) to assist 東京都千代田区岩本町 ３－４－５ （A system for dealing with questions）
A. Contents of information provision

with the procedures 第１東ビル８０１号室

Yes / No
c. Contact information for (In cases (In cases where the (In cases where the details of each case of (In cases where the details of each case of
consultations and complaints, contact where the details of each case of support is different, please explain below) support is different, please explain below)
information of the organization of the details of support is different,
ü Yes（ ）
national or local government where a each case of please explain below)
□ No（ ）
request is to be filed support is
d. Matters concerning medical different,
institutions where the specified skilled please
worker (i) will be able to receive explain
medical treatment in a language that below)
he/she is fully able to understand
e. Matters related to disaster
prevention and crime prevention, and
other necessary matters for responses
at the time of a sudden illness or other
emergencies
f. Method of response on becoming
aware of a violation of laws and
regulations relating to immigration or
labor, and other matters necessary for
legal protection of the specified
skilled worker (i)
Free description □ Yes Postal code － □ Oral
(Other details) Yes / No □ Written (including a translation)
□ No □ Others ( )

B. Language that the support is to be given in Language: Sinhala, English （where there is interpretation provided by someone other than the person in charge of support) Name and position of interpreter

C. Scheduled hours of support Total number of hours:８

 Support staff or implementing staff if the support is to be outsourced
5. Provision of opportunities for Japanese language studies

Outsourced Implementation method

Contents of the support Scheduled implementation Name Address
Yes No (Check all the applicable boxes)
(Title) (Only when outsourced)
a. Provision of information on admission Postal code 〒101－0032
guidance for Japanese language classes and □ Yes（ ）
SUJAN SANDAMAL
Japanese language institutions, and Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
accompanying as needed to assist with 第１東ビル８０１号室
admission procedures
b. Provision of information on Japanese Postal code 〒101－0032
language learning materials for self-learning
and online Japanese language courses, and □ Yes（ ）
SUJAN SANDAMAL
where necessary, obtaining Japanese Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
language learning materials and assisting 第１東ビル８０１号室
with the contract procedures for using online
Japanese language courses
c. Based on an agreement with the specified Postal code 〒101－0032
skilled worker (i), enter into a contract with a □ Yes（ ）
SUJAN SANDAMAL
Japanese language instructor and provide Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
opportunities for the specified skilled worker 第１東ビル８０１号室
(i) to study Japanese
Free description □ Yes Postal code －
(Other details) Yes / No
□ No

Support staff or implementing staff if the support is to be outsourced

Outsourced
6. Responses to consultations or complaints

Contents of the support Scheduled implementation Name Address

Yes No
(Title) (Only when outsourced)
a. Appropriate responses to a request Postal code 〒101－0032
for a consultation or to a complaint in
A. Contents of responses, etc.

a language that can be fully

understood without delay, and giving
of necessary advice and guidance
b. Where necessary, give information □ Yes (implemented in a SUJAN SANDAMAL
timely manner) Yes / No 東京都千代田区岩本町 ３－４－５
on the relevant administrative （Support Person）
organization corresponding to the □ No（ ） 第１東ビル８０１号室
content of the consultation, and assist
with necessary procedures such as
accompanying the specified skilled
worker (i)
Free description □ Yes Postal code －
(Other details) Yes / No
□ No
 Mon Tues Wed Thurs Fri
Weekdays
From 9:00 to 18:00 From : to : From 9:00 to 18 :00 From : to : From 9 :00 to 18:00
Response times

Sat From 9:00 to 18: 00

Sun From : to :

Holidays From : to :
B. Implementation method

Method of consultation

Implemented through the following method (check all the applicable boxes)

ü Direct interview

□ Telephone（ － － ）

□ Email（ ）

□ Others（ ）

Implemented through the following method at times of emergency (check all the applicable boxes)
Emergency responses

□ Direct interview

ü Telephone（ ０３ － ６８０３ － ０６１２ ）

□ Email（ ）

□ Others（ ）

C. Language of consultation Language: Sinhala, English （where there is interpretation provided by someone other than the person in charge of support) Name and position of interpreter
7. Support for promotion of exchanges with Japanese

Support staff or implementing staff if the support is to be outsourced

Outsourced
Contents of the support Scheduled implementation Name Address Implementation method
Yes No
(Title) (Only when outsourced)
a. Where necessary, provision of information Postal code 〒101－0032
on places of interaction with local residents
hosted by local governments and volunteer
groups, and on local community meetings,
nationals

and accompanying the specified skilled

worker (i), where necessary, to assist with
explaining precautions and implementation □ Yes SUJAN SANDAMAL
Yes / No 東京都千代田区岩本町 ３－４－５
methods of each event □ No （Support Person）
第１東ビル８０１号室
b. As information necessary to understand
Japanese culture, provision of information on
local events related to working or living in
Japan, and accompanying the specified
skilled worker (i), where necessary, to assist
with explanations onsite
 Free description □ Yes Postal code －
(Other details) Yes / No
□ No

Support staff or implementing staff if the support is to be outsourced

Outsourced Implementation method
Contents of the support Scheduled implementation Name Address
Yes No (Check all the applicable boxes)
(Title) (Only when outsourced)
a. Obtaining and providing information on □ Yes（ ） Postal code 〒101－0032
the next accepting organization through an SUJAN SANDAMAL
Yes / No 東京都千代田区岩本町 ３－４－５
industry association or affiliated company, □ No（ ） （Support Person）
第１東ビル８０１号室
etc.
8. Support for a job change except where caused by the foreign national

b. Provision of information on public Postal code 〒101－0032

employment agencies and other employment □ Yes（ ） SUJAN SANDAMAL
agencies and accompanying the specified Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
skilled worker (i) to assist as needed with 第１東ビル８０１号室
finding the next accepting organization

c. Preparing a letter of recommendation to Postal code 〒101－0032

enable the specified skilled worker (i) to
receive employment advice or workplace
introductions or to be able to engage in job- □ Yes（ ） SUJAN SANDAMAL
Yes / No 東京都千代田区岩本町 ３－４－５
hunting activities based on the desired □ No（ ） （Support Person）
第１東ビル８０１号室
conditions, skills level, and Japanese
language skills of the specified skilled
worker (i)
d. Mediation to find a place of employment Postal code 〒101－0032
in cases where it is permitted to mediate for □ Yes（ ）
SUJAN SANDAMAL
employment having received permission or Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
notification for a work intermediating 第１東ビル８０１号室
business
e. Granting of paid leave necessary for the □ Yes（ ）
specified skilled worker (i) to engage in job
hunting activities □ No（ ）
f. Provision of information on necessary □ Yes（ ） Postal code 〒101－0032 □ Oral
SUJAN SANDAMAL
administrative procedures when leaving the Yes / No 東京都千代田区岩本町 ３－４－５ □ Written
□ No（ ） （Support Person）
workplace 第１東ビル８０１号室 □ Others ( )
g. When it is expected that support for a job Postal code 〒101－0032
change cannot be properly implemented due □ Yes（ ） SUJAN SANDAMAL
to bankruptcy or some other reason, securing Yes / No 東京都千代田区岩本町 ３－４－５
□ No（ ） （Support Person）
of a person who will be able to provide 第１東ビル８０１号室
support in lieu of the organization
Free description □ Yes Postal code －
(Other details) Yes / No
□ No
 Support manager or support staff
※For column b and the free-entry column, if the support is to be
Outsourced Implementation method
Contents of the support Scheduled implementation outsourced, implementing staff are also acceptable.
Yes No (Check all the applicable boxes)
Name Address
(Title) (Only when outsourced)
Postal code 〒101－0032
9. Conducting of periodic interviews and notification to administrative agencies

a. Conducting of periodic
interviews(at least once every three
months) with the specified skilled □ In person
worker (i) and those who are in charge
Radio, maritime telephone (deep-
of supervising him/her in order to □
confirm the work and living sea fisheries only)
conditions of the specified skilled
worker (i) □ Yes ( )
A. Contents of interviews, etc.

b. Provision of the information □ No（ ）

provided in the general living
orientation in order to go over the
information again
c. Notification to the Labor Standards SUJAN SANDAMAL
Inspection Office or other relevant Yes / No 東京都千代田区岩本町 ３－４－５
（Support Person）
administrative agencies on becoming 第１東ビル８０１号室
aware of a violation of the Labor
Standards Act or other labor-related
laws
Yes (implemented in a
d. Notification to the Regional □
timely manner)
Immigration Services Bureau on
becoming aware of a violation of the □ No（ ）
Immigration Control Act such as the
specified skilled worker (i) engaging
in activities other than those
authorized under the status of
residence, or other problems such as
confiscation of the passport or
residence card
Free description □ Yes Postal code －
(Other details) Yes / No
□ No

B. Language that the support is to be given in Language: Sinhala, English （where there is interpretation provided by someone other than the person in charge of support) Name and position of interpreter
Notes
1. Column I. If there are multiple persons who are to receive support and the contents of the support are the same, for “1 Name” write, “As given in the attached name list”, and attach a name list (no set format) which gives the matters set out in
column I.
2. Column II-4: Fill in this section only if the organization of affiliation of the specified skilled worker itself is to implement the support plan for specified skilled workers (i).
3. Column III: Fill in this section only when entrusting the implementation of all of the support plans for specified skilled workers (i) to a registered support organization.
4. “Scheduled implementation” in Column IV-1 to 9: Check the applicable items, and if the scheduled implementation is “Yes”, briefly describe the implementation time, and if “No”, describe the reasons for not implementing the support in the
parentheses.
5. Only tick "yes" for the "Outsourced" section in Column IV-1 to 9, if the organization of affiliation of the specified skilled worker is to entrust part of the support to a third party (excluding the cases when it is outsourced to a registered support
organization). If the organization of affiliation of the specified skilled worker itself is to provide support or entrust all of the support to a registered support organization, tick "no".
6. "Support staff or implementing staff if the support is to be outsourced" in Column IV-1 to 8: If the organization of affiliation of the specified skilled worker itself is to provide support or entrust all of the support to a registered support
organization, list the names of the appointed support staff, followed by their titles in parenthesis, for each type of support given. If a third party partly entrusted by the organization of affiliation of the specified skilled worker is to provide support,
list the names and addresses of staff entrusted for the support.
"Support manager or support staff" in Column IV-9: If the organization of affiliation of the specified skilled worker itself is to provide support or entrust all of the support to a registered support organization, list the names of the appointed
support manager or support staff, followed by their titles in parenthesis, for each type of support given. In addition, if the support work described in the same column, is performed by the third party partly entrusted by the organization of affiliation
of the specified skilled worker is to provide support, list the names and addresses of staff entrusted for the support in column b and the free-entry column.
7. “Implementation method” in Column IV-1 to 4, 9: Check the applicable items. If you check “Others”, give the method of implementation in the parentheses.
8. With regard to IV Cell 3-A-d, select the appropriate check box from within the parentheses.
9. “Response times” in Column IV-6, B: Give the times for the available days of the week.

I hereby declare that the support will be provided as described above.

In addition, this document has been translated into a language that the recipient of the support is fully able to understand, a copy has been given to the recipient of the support, and the

Name of the organization of affiliation of specified skilled

workers
Name of the person preparing this document

I have received a translation of this document in the language, and I fully understand the contents having had them explained to me.

Date of signature DD/MM/YYYY

Signature of the specified skilled worker (i)

参考様式第１－１６号
Reference Form 1-16

雇 用 の 経 緯 に 係 る 説 明 書

Explanation of Employment Background

特定技能外国人 BODHIPAKSHALAGE NAYANAJITH MADUSANKA RANASINGHE との間で特定技能雇用契

約を締結するに当たっての雇用の経緯は以下のとおりです。
Regarding the conclusion of the employment contract with specified skilled worker _________________, the
employment background is as follows.

１ 職業紹介事業者（国内）
Employment placement business provider (in Japan)
１ あっせんの有無
ü 有 □ 無
Use of an employment
Yes No
placement service i
２ 許可・届出受理番号
（受理受付年月日）
Acceptance No. for １３－ユ－３１４６８０（ ２０２２ 年 ８ 月 ２２ 日）
approval and notification － － （ DD /MM /YYYY ）
(Date of acceptance and
receipt)
３ 職業紹介事業者の区分 ü 有料職業紹介事業者
Category of the □ Fee-charging employment placement business provider
employment placement □ 無料職業紹介事業者
business provider □ Free employment placement business provider
４ 職業紹介事業者の氏名
Name of the employment
株式会社 PMF-JAPAN
placement business
provider
５ 職業紹介事業者の住所 〒１３６－００７１
（電話番号） 東京都江東区亀戸九丁目５番１９－８０３号
Address of the
employment placement （電話番号 ０３－５６２６－３４８４）
business provider （Telephone number － － ）
(Telephone number)

額 （ ３３０，０００ 円）
求職者 Amount （ yen）
（申請人）
Job seeker
(the applicant) 名目 人財紹介手数料として
６ 職業紹介事業者へ支払っ
Description For payment of
た費用
Expenses paid to the 求人者
employment placement 額 （ 円）
（特定技能所属機関） Amount （ yen）
business provider Job offeror
(the organization of
affiliation of the 名目 として
specified skilled Description For payment of
worker)
（注意）
(Notes)
１ １欄で無にチェックを付した場合には，２以下の欄の記載は不要とする。
If you ticked “No” in section 1, you do not need to fill out sections below section 2.
２ ２から５欄までは，厚生労働省職業安定局ホームページの「人材サービス総合サイト」を活用し，当該職業紹介事業者についての該当する
情報を記入すること。また，併せて当該情報が掲載されている画面の写しを添付すること。
Fill in the relevant information for the applicable employment placement business provider in sections 2, 3, 4, and 5, using the
“Comprehensive Human Resource Services Website” which is operated by the Employment Security Bureau of the Ministry of Health, Labour
and Welfare. Furthermore, attach a copy of the screen on which the information in question is posted.
３ ６欄は，求職者及び求人者が職業紹介事業者に支払った額及び名目について記載すること。なお，求職者が日本円以外で費用を支払った場
合は，当該通貨で支払った額及び日本円に換算した額を記載すること。
Fill in the amount and description of the money paid by the job seeker and job offeror to the employment placement business provider in
section 6. Please note that if the job seeker paid the expense in a currency other than yen, you must state the amount paid in the local
currency, as well as that amount converted to yen.
４ 職業紹介事業者との間で交わした契約書があれば，その写しを添付すること。
If you have a written contract exchanged with the employment placement business provider, please attach a copy of it.

２ 取次機関（国外）（１で有にチェックを付した場合のみ記載）
Agent organization (outside Japan) (Only those who ticked “Yes” in section 1 above need to fill in the form
below)
１ 取次ぎの有無
□ 有 □ 無
Use of service provided by
Yes No
the agent organization
２ 氏名又は名称
Name of the agent
organization
３ 所在国
Country where the agent
organization is located
４ 所在地
Address of the agent （電話番号 － － ）
organization （Telephone number － － ）

額 （ 円）
求職者 Amount （ yen）
（申請人）
Job seeker
(the applicant) 名目 として
５ 取次機関へ支払った費用 Description For payment of
Expenses paid to the
求人者
agent organization 額
（特定技能所属機関） （ 円）
Job offeror Amount
（ yen）
(the organization of
affiliation of the 名目 として
specified skilled Description For payment of
worker)
（注意）
(Notes)
１ 取次機関とは，職業紹介事業者が求人者に求職者のあっせんを行うに際し，当該職業紹介事業主に対し求職者等に係る情報の取次ぎを行う
者をいう。
The agent organization means the party that acts as the agent handling the job seeker’s information for the applicable employment
placement business provider, in the case where the job offeror uses the employment placement service provided by the employment
placement business provider to recruit the job seeker.
２ １欄で無にチェックを付した場合には，２以下の欄の記載は不要とする。
If you ticked “No” in section 1, you do not need to fill out sections below section 2.
３ ５欄は，求職者及び求人者が取次機関に支払った額及び名目について記載すること。なお，求職者及び求人者が日本円以外で費用を支払っ
た場合は，当該通貨で支払った額及び日本円に換算した額を記載すること。
 Fill in the amount and description of the money paid by the job seeker and job offeror to the agency organization in section 5. Please note that
if the job seeker and job offeror paid their expenses in a currency other than yen, you must state the amount paid in the local currency, as well
as that amount converted to yen.
４ 取次機関との間で交わした契約書があれば，その写しを添付すること。
If you have a written contract exchanged with the agency organization, please attach a copy of it.

３ 事前ガイダンスの実施
Conducting of guidance in advance
第１号特定技能外国人支援計画に定めるとおりに実施していることの有無 有 ・ 無
Is guidance being conducted according to "Support Plan for Specified Skilled Yes/No
Worker (i)"?

以上の１から３までの内容について相違ありません。なお，求職者（申請人）が在留資格「特定技能」の活動
を行うことに関連して保証金，違約金の支払等の不適切な費用徴収がされていないことを本人から聞き取るな
どして確認しています。
There are no discrepancies with regard to 1 to 3 above. Further, it has been confirmed by, for example, asking
the person himself/herself that there has not been any inappropriate levying of fees such as a deposit or
penalty payment on the job seeker (applicant) in connection with his/her activities related to the "specified
skilled worker" status of residence.

作成年月日： 年 月 日
Prepared on DD /MM /YYYY

特定技能所属機関の氏名又は名称 株式会社フォンス

Name of the organization of

affiliation of the specified skilled worker

作成責任者の氏名及び役職 人事総務担当 南波由紀

Name and title of the person

responsible for preparing this document

４ 求職者（申請人）が自国等の機関に支払った費用
Fees paid by the job seeker (applicant) to organization in his/her country, etc.
支払先機関の名称 名目 支払年月日 支払金額
Name of organization Name of item Date of payment Amount paid
to which payment has
been made

年 月 日
1 （ 円）
mm/dd/yyyy
( yen)
 年 月 日
2 （ 円）
mm/dd/yyyy
( yen)

年 月 日
3 （ 円）
mm/dd/yyyy
( yen)

年 月 日
4 （ 円）
mm/dd/yyyy
( yen)

年 月 日
5 （ 円）
mm/dd/yyyy
( yen)
計
（ 円）
Total
( yen)
（注意）
(Notes)
１ 自国等の機関は，特段対象を限定するものではなく，特定技能雇用契約の申込みの取次ぎ又は活動の準備に関与した全ての機関をいう。
The term "his/her country, etc." does not refer to particular institutions, but rather means institutions involved in accepting applications for
specific skilled employment contracts or in the preparation of activities, without limiting the scope of the subject matter in any particular
way.
２ 支払金額については，現地通貨又は米ドルで記載し，括弧書きで日本円に換算した金額を記載すること。
With regard to "Amount paid," write it in local currency or US dollars and write in the parenthesis the value converted into yen.
３ 名目については，申請人に示した名目どおりに記載すること。
With regard to "Name of Item," write the name as expressed to the applicant.

特定技能雇用契約の申込みの取次ぎ又は在留資格「特定技能」に係る活動の準備に関して，自国
等の機関に対し，上記の費用の額及び内訳について十分に理解した上で支払いました。また，上
記の費用以外の費用については，徴収されていません。

I have paid the above fees with amounts and details as described above to organizations in my
country, etc. with a full understanding of the amount and breakdown of the costs involved in acting
as an agent for applications for specified skilled worker employment contracts or in preparing for
activities related to the "specified skilled worker" status of residence. Furthermore, no other fees
other than the above have been collected from me.

申 請 人 の 署 名

Signature of the applicant

 記第 号 式（第 ）
人 １
For applicant, part 1 Ministry of Justice, Government of Japan

APPLICATION FOR CERTIFICATE OF ELIGIBILITY

To the Minister of Justice

P oto
第７ ２ 第７ 第１ 第２号
0 30
Pursuant to the provisions of Article 7-2 of the Immigration Control and Refugee Recognition Act, I hereby apply for
the certificate showing eligibility for the conditions provided for in 7, Paragraph 1, Item 2 of the said Act.

Nationality/Region
ス ン Date of birth
1 2 Year
3 Month
2 Day

Name
D PA S ALA NAYANAJ MADUSAN A ANAS N
Family name Given name

Sex Male / Female Place of birth

ス ン Marital status Married / Single

Occupation
会社 Home town/city
ス ン

Address in Japan
長野県北佐久郡軽井沢町軽井沢 10 -
号 号
Telephone No. Cellular phone No.
0 0- 2 - 3
号
Passport Number
N６５５４１６２ Date of expiration
202 Year
1 Month Day
（ ） Purpose of entry: check one of the followings
□ □ □ □ □ □
"Professor" "Instructor" "Artist" "Cultural Activities" "Religious Activities" "Journalist"
□ □ （ ） □ □ □
"Intra-company Transferee" "Researcher (Transferee)" "Business Manager” "Researcher" "Engineer / Specialist in Humanities / International Services"
□ □ □ （ ） □ （ ）
"Nursing Care" "Skilled Labor" "Designated Activities ( Researcher or IT engineer of a designated org)" "Designated Activities (Graduate from a university in Japan)"
（ 号） □ （ 号） □ □ □
"Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) " "Entertainer" "Student" "Trainee"
□ （ 号） □ （ 号） □ （ 号） □
"Technical Intern Training " "Technical Intern Training " "Technical Intern Training " "Dependent"
□ （ ） □ （ A ） □ （ ）
"Designated Activities (Dependent of Researcher or IT engineer of a designated org)" "Designated Activities(Dependent of EPA)" "Designated Activities(Dependent of Gradutate from a university in Japan)"
□ □ □
"Spouse or Child of Japanese National" "Spouse or Child of Permanent Resident" "Long Term Resident"
□ （ 号 ） □ （ 号 ） □ （ 号 ） □
"Highly Skilled Professional(i)(a)" "Highly Skilled Professional(i)(b)" "Highly Skilled Professional(i)(c)" Others

Date of entry
2023 Year Month
2 Day Port of entry
東京 田国

Intended length of stay

５ Accompanying persons, if any Yes / No

Intended place to apply for visa

ス ン 本

Past entry into / departure from Japan Yes / No

（ ） (Fill in the followings when the answer is "Yes")

1 time(s) The latest entry from

201 Year Month
2 Day to
2020 Year Month
1 Day

Past history of applying for a certificate of eligibility Yes / No

（ ） （ ）
(Fill in the followings when the answer is "Yes")
1 time(s) （Of these applications, the number of times of non-issuance） time(s)

（ ）※
Criminal record (in Japan / overseas)※Including dispositions due to traffic violations, etc.
（ ）
Yes ( Detail: ) / No

Departure by deportation /departure order Yes / No

（ ）
(Fill in the followings when the answer is "Yes") time(s) The latest departure by deportation Year Month Day
（ ）
Family in Japan (father, mother, spouse, children, siblings,grandparents, uncle, aunt or others) and cohabitants
（ ）
Yes (If yes, please fill in your family members in Japan and co-residents in the following columns) / No
号
号
Intended to reside Residence card number
Relationship Name Date of birth Nationality/Region
with applicant or not Place of employment/school Special Permanent Resident Certificate number

Yes / No

Yes / No

Yes / No

Yes / No
※
Regarding item 3, if you possess your valid passport, please fill in your name as shown in the passport.
,
Regarding item 21, 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”.

（ ） 参
Note : Please fill in forms required for application. (See notes on reverse side.)
（ ）
Note : In case of to be found that you have misrepresented the facts in an application, you will be unfavorably treated in the process.
 人 ２ （ 特定技能（１号） 特定技能（２号） ）
For applicant, part 2 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) ") For certificate of eligibility
Organization of affiliation of the specified skilled worker

Name of person or organization

株式会社フォンス
（ ） 号
Address
長野県北佐久 軽井沢町 軽井沢 １０７５－４
Telephone No.
０２６７－４１－３７７７
Skill level
Proof based on the evaluation method specified in the field-specific operational policy

Proof based on the passing of an exam

Name of passed exam Exam location
□ Japan
外 業特定技能 定
（ ）
Foreign country
Country name
□ Japan
□ （ ）
Foreign country
Country name
□
Proof based on some other evaluation method

□ 号 Successfully completed Technical Intern Training (ii)

（ 号 ）
Japanese language ability (Fill in this section if you wish to enter Japan with the status of residence of "Specified Skilled Worker (i)")
Proof based on the evaluation method specified in the field-specific operational policy

Proof based on the passing of an exam

Name of passed exam Exam location
□ Japan
本 能 N４
（ ）
Foreign country
Country name
□ Japan
□ （ ）
Foreign country
Country name
□
Proof based on some other evaluation method

□ 号 Successfully completed Technical Intern Training (ii)

号（ 号 ）
Technical Intern Training (ii) that was successfully completed (Fill in this section if you selected "Successfully completed Technical Intern Training (ii) in 223 and 234 above)

（ 第 ）
Occupation / Operations (Fill in the occupation /operations under Appended Table II of the Ordinance for Enforcement of the Act on Proper Technical
Intern Training and Protection of Technical Intern Trainees)

Occupation Operations
Proof of successful completion
□
Proof based on passing Grade 3 of the National Trade Skills Test or the practical test of an equivalent technical intern training evaluation exam

□
Proof based on a document relating to the status of the technical intern training
（ ） (Fill in (2) if you have several forms of proof)
（ 第 ）
Occupation / Operations (Fill in the occupation /operations under Appended Table II of the Ordinance for Enforcement of the Act on Proper Technical
Intern Training and Protection of Technical Intern Trainees)

Occupation Operations
Proof of successful completion
□
Proof based on passing Grade 3 of the National Trade Skills Test or the practical test of an equivalent technical intern training evaluation exam

□
Proof based on a document relating to the status of the technical intern training
号 （ 号
）
Cumulative period of stay with "Specified Skilled Worker (i)" at the time of submitting this application (including past residence history; fill in this section if
you wish to enter Japan with the status of residence of "Specified Skilled Worker (i)")

Year
0 Month
 人 ３ （ 特定技能（１号） 特定技能（２号） ）
For applicant, part 3 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) ") For certificate of eligibility

Is there a contract on the collection of a deposit pertaining to the employment contract for a specified skilled worker, or management of other property or the payment of penalties, etc.?

（ ）
Yes (Name of the organization collecting the deposit or managing property: Deposit amount or type of property managed: ) / No

（
） Do you fully understand and agree on the amount and breakdown of expenses to be paid to the organization in a foreign country
concerning mediation for the application pertaining to the employment contract for specified skilled workers or preparations for
activities in the foreign country? (Fill in this section if there are expenses to be paid.)
（ （ ） ）
Yes (Name of the organization in a foreign country: Payment (converted into Japanese yen) : Approximately Yen) / No

（ ）
Have you followed the procedures to be complied with in relation to the activities to be conducted in Japan prescribed by the country or Yes / No
region of nationality or residence? (Fill in this section if such procedures are prescribed.)

（ ）
Do you fully understand and have you agreed to the expenses to be paid on a regular basis in Japan? (Fill in this section if there are expenses to be paid.) Yes / No

（ 号
）
Will you endeavor to transfer the skills, etc. you acquire, the skills, etc. for which you increase proficiency or attain proficiency in Japan Yes / No
through the technical intern training? (Fill in this section if you have a previous history of residing in Japan with the status of residence of
"Technical Intern Training", and wish to enter Japan with the status of residence of "Specified Skilled Worker (ii)".)

（ ）
Do you meet the criteria prescribed in the public notice in consideration of circumstances specific to the specified industrial field pertaining Yes / No
to you? (Fill in this section if such criteria are prescribed.)

（ ） Work experience (including those in a foreign country)

Date of joining the company Date of leaving the company Date of joining the company Date of leaving the company

Place of employment Place of employment

Year Month Year Month Year Month Year Month

第７ ２第２
(Applicant, legal representative or the authorized representative, prescribed in Paragraph 2 of Article 7-2.)

Name Relationship with the applicant

Address
東京都 区 1- -3 2
号 号
Telephone No. Cellular Phone No.
0 0- 2 - 3

I hereby declare that the statement given above is true and correct.
（ ） Signature of the applicant (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 (representative) must correct the part concerned and sign their name.
The date of preparation of the application form must be written by the applicant (representative).
※ Agent or other authorized person

Name Address
東京 区東 １－３１－５ ン８０１
Organization to which the agent belongs 号 Telephone No.

国 書 ０８０－３７２１ １７００
 １ （ 特定技能（1号） 特定技能（2号） ）
For organization, part 1 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) ") For certificate of eligibility

D PA S ALA NAYANAJ MADUSAN A ANAS N

Name of foreign national being offered a contract
Employment contract for a specified skilled worker

Period of employment contract from 2023 Year Month

1 Day to 202 Year Month
30 Day

（ ）
Contents of work to be engaged in (if there are several types of work, fill in all of the work)

Specified industrial field

外 業 Work category
外 業

号 （１ ）
Occupation Select the main occupation from the Attachment: "Occupations List", and fill in the number (select only one)
2
号 （ ）
If there is any other occupation, select from the Attachment: "Occupations List", and fill in the number (more than one answer may be selected)
） Attention
※ , , , ,
Please select from 1 to 43,from 45 to 50,from 55 to 81,from 100 to 112 and 999 on the attached "Occupations List."
） （ ）
Prescribed working hours (weekly average) hours Prescribed working hours (monthly average)
1 1/1 hours

Are the prescribed working hours equivalent to the prescribed working hours of regular workers? Yes / No
※ （ ）
Monthly remuneration
1 Yen Excludes various types of allowances (commuting,housing,dependents,etc.) and personal expenses. Time converted amount of basic salary
0 Yen

Monthly remuneration of Japanese national engaging in the same type of work

1 Yen

Will the foreign national receive an equal or greater amount of remuneration than a Japanese national would receive for comparable work? Yes / No
□
Payment method of remuneration Paid in cash Paid into a bank account

Are any matters stipulated related to treatment that differ from that given to a Japanese national due to the applicant being a foreign national?
（ ）
Yes (Details: ) / No

Will the foreign national be given the necessary paid holidays in the event of wanting to return temporarily to his/her home country? Yes / No
（
） Are the criteria, which are stipulated in a public notice in consideration of circumstances specific to the specified
industrial field in terms of the employment relations, being met? (Fill in this section if such criteria are stipulated.) Yes / No

If a foreign national cannot afford the travel expenses for return to his/her home country after the end of the employment contract for specified Yes / No
skilled workers, will the organization of affiliation pay for the travel expenses and take necessary measures to ensure smooth departure?

Is the organization of affiliation taking the necessary measures to check the state of the foreign national’s health and other living conditions? Yes / No

（ ）
Are the criteria, which are stipulated in a public notice in consideration of circumstances specific to the specified industrial field in terms of the Yes / No
matters necessary to ensure the proper residence of the foreign nationals, being met? (Fill in this section if such criteria are stipulated.)
（ ）
Dispatch site (Fill in this section if the foreign national may be sent out for worker dispatch)
号（ ）
Name of person or Corporation no.
organization (combination of 13 numbers
and letters)
号（ ）※ Employment insurance application office number (11 digits) *If not applicable, it should be omitted.

（ ） 号
Address Telephone No.

Name of the representative

Period of dispatch from Year Month Day to Year Month Day

（ ）
Employment placement service provider (fill in this section if there is an employment placement service provider that arranges the conclusion of employment contracts for specified skilled workers)

株式会社PM -JAPAN 号（ ）
0 1 0 0 1 0 0 3 0
Name of person or Corporation no.
organization (combination of 13 numbers
and letters)
号（ ）※ Employment insurance application office number (11 digits) *If not applicable, it should be omitted.

（ ） 号
Address
東京都 東区 1 - 03号 Telephone No.
03- 2 -3
号
Permission / notification no.
13- -31 0 Date of receipt
2022 Year
11 Month
1 Day
 2 （ 特定技能（1号） 特定技能（2号） ）
For organization, part 2 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) ") For certificate of eligibility
（ ）
Intermediary organization (fill in this section if there is a person who mediates information at the time of an employment placement service provider acting as an agent)

Name of person or organization

（ ） 号
Address Telephone No.
Organization of affiliation of the specified skilled worker
※ For sub-items (3) and (8), fill in the information of principal place of business where foreign national is to work
号（ ）
Name of person or 株式会社フォンス Corporation no. (combination of 1 0 0 0 0 1 0 0 2
organization 13 numbers and letters)
※ Fill in the name of head office or principal place of business

号（ ）※
Employment insurance application office number (11 digits) *If not applicable, it should be omitted.

号 （１ ）
Business type Select the main business type from the attached sheet "a list of business type " and write the corresponding number (select only one)
0
号 （ ）
If there are another other business types, select from the attached sheet "a list of business type " and write the corresponding number (multiple answers possible)

（ ） ※
Address of person or organization Fill in the address of head office or principal place of business
号
長野県北佐久 軽井沢町軽井沢 １０７５－４７ Telephone No.
０２６７－４１－３７７７
（ ）
Capital
10００ Yen Annual sales (latest year)
９４ Yen

Number of full-time employees

Name of the representative

井
株式会社フォンス
（ ス ン沢 軽井沢）
長野県北佐久郡軽井沢町軽井沢 12-1
Name of place of business Address
where foreign national is to work

Does the place of business apply health insurance and employees pension insurance? Yes / No

Does the place of business apply industrial accident insurance and employment insurance? Yes / No
号
－ － － － －
Labor insurance number
（ ４ ）
(Enter the last four digits only when they have been allocated.)
Has the organization ever been in violation of the provisions of laws and regulations concerning labor, social insurance or tax?
（ ）
Yes (Details: ) / No

Has a worker who engaged in work of the same type as that which the foreign national is to engage in ever been forced to leave within one year prior to the date of
the foreign national entering into the employment contract for specified skilled workers or after the date of the foreign national entering into such contract?
（ ）
Yes (Details / Reason: ) / No

Has the organization ever caused a foreign national to disappear due to a cause attributable to the fault of the organization of affiliation of the specified skilled worker

within one year prior to the date of the foreign national entering into the employment contract for specified skilled workers or after the date of the foreign national entering into such contract?
（ ）
Yes (Details: ) / No

Has the organization of affiliation of the specified skilled worker or its officer, support manager or support staff ever been sentenced to a criminal punishment due to a violation of laws and regulations?
（ ）
Yes (Details/Name of applicable person: ) / No

Does the organization of affiliation of the specified skilled worker, its officer, support manager or support staff have a mental disability which will have an
impact on proper performance of the employment contract for specified skilled workers?
（ ）
Yes (Details/Name of applicable person: ) / No

Has the organization of affiliation of the specified skilled worker, its officer, support manager or support staff become subject to the commencement of bankruptcy procedures and yet to have its rights restored?

（ ）
Yes (Details/Name of applicable person: ) / No
第 第
Has the organization of affiliation of the specified skilled worker, its officer, support manager or support staff ever had its accreditation of the training revoked as provided for in Article
16, paragraph (1) of the Technical Intern Training Act?
（ ）
Yes (Details/Name of applicable person: ) / No
第 第
Has the organization of affiliation of the specified skilled worker, its officer, support manager or support staff ever been an officer of a corporation
that has had its accreditation of training revoked as provided for in Article 16, paragraph (1) of the Technical Intern Training Act?
（ ）
Yes (Details/Name of applicable person: ) / No

Has the organization of affiliation of the specified skilled worker, its officer, support manager or support staff ever committed a wrongful or seriously unjust act in relation to immigration
or labor-related laws or regulations within five years of the date of entering into the employment contract for specified skilled workers or after the date of entering into such contract?
（ ）
Yes (Details/Name of applicable person: ) / No

Is the organization of affiliation of the specified skilled worker, its officer, support manager or support staff currently an organized crime member or was it formerly an organized crime member within the past five years?

（ ）
Yes (Details/Name of applicable person: ) / No
（ ）
（ ）
Does the statutory agent (its officer in the case of a corporation) of the organization of affiliation of the specified skilled worker, its officer, support manager or
support staff fall under any of (14) to (20)? (Fill in this section if the organization of affiliation of the specified skilled worker, its officer, support manager or support
staff is a minor who does not have the same capacity to act as a person who has reached the age of majority in relation to business.)
（ ）
Yes (Details/Name of applicable person: ) / No
 3 （ 特定技能（1号） 特定技能（2号） ）
For organization, part 3 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) ") For certificate of eligibility

Is an organized crime member or a person who was formerly an organized crime member within the past five years controlling the business activities of the organization of affiliation of specified skilled workers?
（ ）
Yes (Details: ) / No
１
Is the organization taking measures to prepare documents on the contents of the activities of the foreign national, and to keep them at the place of
business where the foreign national is engaging in the activities for at least one year from the date of termination of the contract? Yes / No

Has the organization entered into an employment contract for specified skilled workers knowing about the existence of an agreement to collect a deposit
or to control property or to demand payment of penalties pertaining to the employment contract for specified skilled workers?
（ ）
Yes (Details: ) / No

Has the organization entered into an agreement on the payment of penalties, etc. with regard to non-performance of the employment contract for specified skilled workers?
（ ）
Yes (Details: ) / No
１号 （
号 ）
Has the organization established practical measures to ensure the foreign national is not being made to pay either directly or indirectly for the costs required for Yes / No
support for Specified Skilled Worker (i)? (Fill in this section if the applicant wishes to enter Japan under the status of residence of "Specified Skilled Worker (i)".)
（ ） (Fill in sections (27) and (28) if the foreign national is likely to be sent as a dispatch worker.)
Whether it falls under any of the following cases:
（ ） (If "Yes", choose the corresponding item) Yes / No
□
A dispatch site conducting work pertaining to a specified industrial field to which the work the foreign national is to engage in at the dispatch site belongs or related work
（ ）
(Details: )
□
A local government or a person who falls under who has invested a majority of the stated capital
（ ）
(Details: )
□
A local government or a person who falls under who is substantially involved in execution of the business
（ ）
(Details: )
□ 第 第

The field of work the foreign national is to engage in at the dispatch site is agriculture, and the organization is the specified organization prescribed in Article
16-5, paragraph (1) of the National Strategy Special Zone Act.

Will the organization be sending dispatch workers to a dispatch site that comes under (11) to (22) above?
（ ）
Yes (Details: ) / No
Have measures been taken for coverage of industrial accident insurance, etc.?
（ ）
Yes (Details: ) / No

Is there an appropriate structure in place to ensure continuous implementation of the employment contract for specified skilled workers? Yes / No

長
Will the foreign national's remuneration be paid by wire transfer to the account of a bank or other financial institution specified
by the foreign national or using a method where the actual amount that was paid can be confirmed, and in the latter case, will objective materials proving the Yes / No
payment of remuneration be submitted to the Commissioner of the Immigration Services Agency in order to be checked?

（ ）
Does the organization meet the criteria stipulated in the public notice in consideration of circumstances specific to the specified industrial field in terms of securing Yes / No
the proper performance of the employment contract for specified skilled workers? (Fill in this section if such criteria are stipulated.)
（ 号 号
） (Fill in sections (33) to (41) if the applicant wishes to enter Japan with the status of residence of "Specified Skilled Worker (i)",
and not all of the support plans for specified skilled workers (i) are to be entrusted to a registered support organization based on a contract.)

Support manager Title and department

Has a support manager been appointed from among the officers or employees? Yes / No

Support staff Title and department

Has at least one support staff member been appointed from among the officers and employees for each place of business where the specified skilled worker is to work?Yes / No

Whether it falls under any of the following cases:

（ ） (If "Yes", choose the corresponding item) Yes / No

□ 第 （
） 長
It has a past record of properly accepting or managing mid to long-term residents residing with one of the statuses of residence in the left-hand column of
Appended Table I (1), (2) or (5) over the past two years (limited to the statuses of residence where the foreign national is permitted to engage in activities related to
the management of business involving income or activities for which he or she receives remuneration).
□ 第 （
） 長
The support manager and support staff have experience of engaging in the work of providing advice on living for mid to long-term residents
with a status of residence in the left-hand column of Appended Table I (1), 2 and (5) (limited to the statuses of residence where the foreign
national is permitted to engage in activities related to the management of business involving income or activities for which they receive
□ （ ）
Other conditions to ensure support is properly implemented (Details:
号

Do you have a structure in place where support based on the support plan for specified skilled workers (i) will be provided in a language that the foreign national is
able to fully understand? Yes / No
号 号

Has the organization taken measures to prepare documents on the status of support for specified skilled workers (i), and to keep them at the place of business
where the support for specified skilled workers (i) is to be implemented for at least one year from the date of termination of the employment contract for specified Yes / No
skilled workers?
 （ 特定技能（1号） 特定技能（2号） ）
For organization, part 4 V ("Specified Skilled Worker ( i ) " "Specified Skilled Worker ( ) ") For certificate of eligibility
号
Are the support manager and support staff in a position where they are able to implement the support plan for specified skilled workers (i) in a neutral manner?
Yes / No
号 号

Has the organization failed to implement support for specified skilled workers (i) based on a suitable support plan for specified skilled workers (i) within five years prior to the date of entering into the
employment contract for specfied skilled workers or after the date of entering into such contract?
（ ）
Yes (Details: ) / No

Is there a system in place to ensure the support manager and support staff are able to conduct periodic interviews with the foreign nationals and their supervisors?
Yes / No
号
（ ）
Does the organization conform to the criteria stipulated in a public notice in consideration of circumstances specific to the specified industrial field in terms of ensuring proper Yes / No
implementation of the support plan for specified skilled workers (i)? (Fill in this section if such criteria are stipulated.)
号 （ 号 ）
Support plan for specified skilled workers (i) (fill in this section if the applicant wishes to enter Japan with the status of residence of "Specified Skilled Worker (i)")

Did the organization provide information to the specified skilled worker (i) in a language that can be fully understood by the specified skilled worker (i) before their application for
certificate of eligibility the contents of the employment contract for specified skilled workers, the contents of the activities that may be conducted in Japan, the conditions for Yes / No
landing and residence, and other points to be noted when landing and staying in Japan?

With regard to (1) above, will this be conducted face-to-face, using video call equipment or some other method? Yes / No

Will the organization be picking up and dropping off the foreign national at the seaport or airport where he / she will be entering or departing from Japan? Yes / No

Will the organization be providing support to secure suitable accommodation for the foreign national? Yes / No

Will the organization be providing support related to contracts concerning the opening of bank accounts, etc. or the use of mobile phones and other contracts necessary for living? Yes / No

Yes / No
Will the organization be providing information after the specified skilled worker (i) has entered Japan in a language which the specified skilled worker (i) is fully able to
understand on matters concerning general living in Japan, notifications to national or local government agencies and other procedures, contact information for consultations or
filing of complaints, matters concerning medical institutions capable of providing medical care in a language that the specified skilled worker (i) is fully able to understand,
matters on disaster prevention and crime prevention, necessary matters for responses in case of emergency, and necessary matters for legal protection of foreign nationals?

Will the organization take necessary measures to accompany the foreign national,where necessary, to the relevant
agency in order to submit a notification to a national or local government agency or for other procedures that need to Yes / No
be followed?

Will the organization be providing the foreign national with opportunities to learn Japanese? Yes / No

Will the organization respond appropriately to requests for consultations or to complaints without delay, and take
necessary measures n a language which the specified skilled worker (i) is fully able to understand ? Yes / No

Will the organization provide support for the promotion of exchanges between foreign nationals and Japanese nationals? Yes / No

Will the organization provide support to foreign nationals whose employment contract for specified skilled workers has been cancelled due to causes not
attributable to the fault of the foreign national so as to enable the foreign national to change jobs? Yes / No
（
）
Will the support manager or support staff conduct periodic interviews with foreign nationals and their supervisors (when conducting an interview with a foreign national, in a
language which the foreign national is fully able to understand), and when they learn about a problem, report the problem to the relevant administrative agency? Yes / No
１号
Has a support plan for specified skilled workers (i) been prepared in Japanese and in a foreign language that can be fully
understood by the foreign national, and a copy been given to the foreign national? Yes / No
１号 （
） Have the matters stipulated in a public notice in consideration of circumstances specific to the specified industrial field been given in the
support plan for specified skilled workers (i)? (Fill in this section if such matters are stipulated.) Yes / No

Will the contents of the support contribute to the proper residence of the foreign nationals, and can they be appropriately implemented by those providing the support? Yes / No
１号 （
） Will the organization conform to the criteria stipulated in a public notice in consideration of the circumstances specific
to the specified industrial field in terms of the contents of the support plan for specified skilled workers (i)? (Fill in this section if such criteria are stipulated.) Yes / No

（ 号 号
） Registered support organization
(Fill in this section if the applicant wishes to enter Japan with the status of residence of "Specific Skilled Worker (i)",
and all of the support plans for specified skilled workers (i) are to be entrusted to a registered support organization based on a contract.)
号（ ）
Name of person or
株式会社 ス Corporation no. (combination 0 3 0 0 0 1 1 0 3 1
organization of 13 numbers and letters)

号（ ）※
Employment insurance application office number (11 digits) *If not applicable, it should be omitted.

（ ） 号
Address
東京都千代田区岩本町 ３－４－５ 第１東 ８０１号室 Telephone No.
０３－６８０３－０６１２

Name of the representative

長

号
Registration no.
１９登-00０４９１ Date of Registration
201 Year Month
11 Day

Name of place of businessimplementing support

株式会社 ス Address
東京都千代田区岩本町 ３－４－５ 第１東 ８０１号室

Support manager
長 Support staff
SUJAN SANDAMAL

（ ）
Available languages
ン Support commission fee (person per month)
, Yen

I hereby declare that the statement given above is true and correct.

Name of the organization and representative of the organization Date of filling in this form

株式会社フォンス 代 井 2023 Year Month

1 Day

Attention

In cases where descriptions have changed after filling in this application form up until submission of this application, the organization must correct the changed part.