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Questionnaire for Application for Certificate of Eligibility (Form B)Issue of a Certificate of Eligibility, mandatory to a Japanese visa, requires completion of thefollowing questionnaire. False, misleading, incorrect or incomplete information will result inunfavorable treatment at the Immigration Bureau in Japan.1. NameFamily nameGiven namesName in Chinese character,if applicable:2. Nationality 3. Sex Male Female4. Date of Birth5. Place of BirthYear Month Day6. Marital Status Married Single 7. Current town/city of residence8. Passport No. Date of expirationYear Month Day9. Accompanying persons, if any Yes No10. Place applying for Japanese visa (city in your country)11. Past entry into/ stay in Japan Yes, ___________time(s)(Most recent stay in Japan: from ______________ to _______________)12. Criminal record (in Japan or overseas) Yes (Details: No) No13. Family in Japan (Father, Mother, Spouse, Son, Daughter, Brother, Sister or others)and/or any co-residentsRelationship Name Date of birth NationalityResiding withapplicantor notPlace ofemployment / schoolStatus ofresidence14. Total period of education(from elementary school to last institution of education)15. Date of expected graduation (from your home institution) Year Month Day16. Method of financial support while in JapanA. Average anticipated monthly support and method of payment (circle if applicable)(1) Money you bring with you: ______________ yen(2) Money which will be sent from abroad: ___________ yen(3) Money which someone brings you from abroad: ___________ yen(4) Money from guarantor in Japan supports you: ____________ yen(5) Scholarship:______________ yen(6) Other: _____________ yenOrganization providing scholarship:Foreign governmentRegional bodyI hereby declare that the information given above is true and correct.Japanese governmentPublic corporationOther ( )B. Benefactor (If you circled (2), (3) or (4) in answer to above question, who supports you financially?)Name:Address:Occupation (Name of employer):Annual income: _______________ yenRelationship to applicant:Phone:Phone:yearsSignature of applicant_______________________________Date________________________