Previous last name or Nickname (Appellation)
【手書用】
個人番号カード交付申請書 兼 電子証明書発行/更新申請書 [to be personally handwritten]
INDIVIDUAL NUMBER CARD Issuing Application / Digital Certification Form
地方公共団体情報システム機構 宛 Japan Agency for Local Authority
(To: 長宛)
個人番号※(注記)1
ID Number
氏名※(注記)2Name住所※(注記)2
Address
生年月日※(注記)2
Date of Birth
性別※(注記)2
Gender
男・女
Male・Female
旧氏又は通称
※(注記)2・3
電話番号※(注記)4
Phone Number
外国人住民の区分
Foreign Residency
Status
点字※(注記)5
Braille Type
点字表記を希望する(最大 24 文字まで、濁点等は 1 文字) □しろいしかく
Request Braille (maximum 24 characters, sonant mark counts as 1)
在留期間等満了日の
有無
Residency expiry
date available or not
在留期間等満了日
Residency expiry
date available or not
※(注記)1 If the information you provide includes any errors, the Individual Number Card nor Digital Certificate details may result in issuing incorrectly. Please make certain to submit the
correct information.
※(注記)2 Concerning your name, address, date of birth, and gender, the information on the Certificate of Residence will be indicated on the Individual Number Card and the Digital Certificate .
※(注記)3 If you have already completed the procedure to list your previous last name or nickname on the Certificate of Residence, the previous last name or nickname will be indicated on
the Individual Number Card and the Digital Certificate.
※(注記)4 If the information is insufficient, you may be contacted. Please submit your phone number where we can reach you during the daytime.
※(注記)5 If you prefer your name in braille, please black out the □しろいしかく. The furigana, or katakana, spelling (up to 24 characters, symbols such as「" 」or「。」 count as one character.)
registered as identification information, on the Basic Resident Registration Network System is transcribed into braille.
以上の内容に間違いのないことを確認しましたので、個人番号カードの交付及び電子証明書発行を申請します。
I herein certify the statement in this document is true and correct with the best of my knowledge. I request to apply for an Individual
Number Card and Digital Certificate.
申請日 Application 年 月 日
year month day
申請者氏名
Applicant’s Name
【ご注意】を必ずご確認いただき、電子証明書の発行を受けないこととする場合は、□しろいしかくを黒く塗りつぶしてください。
Please make sure to confirm [Note], and black out the □しろいしかく box if you do NOT wish to issue a Digital Certificate.
□しろいしかく 署名用電子証明書※(注記)
Electronic certificate of the bearer's signature*
□しろいしかく 利用者証明用電子証明書
Electronic certificate of user proof.
【ご注意】電子証明書は、健康保険証としての利用、住民票の写しなどのコンビニ交付
サービス、e-Tax 等の電子申請、マイナポータルへのログインなど多様なサービスの提供
に必要となります。
[Note] The Digital Certificate is required for various services, such as an alternative health
insurance card use, convenience store issuing service (e.g., issuing a copy of the Certificate of
Residence), e-Tax online filing, and logging in to the Individual Number portal.
※(注記)15 歳未満の方、成年被後見人の方には原則発行されません。
* As a general rule, the certificate is not issued for a person under 15 years of age and for an adult ward.
When the bearer under the age of 15 years, or adult ward applies to issue an Individual Number Card and Digital Certificate, please fill in the representative's
name, address, phone number and relationship below:代理人記載欄
Statutory
Representative
ふりがな
Furigana
本人との関係
Relation To
Applicant
代理人氏名
Representative Name
代理人住所
Representative’s
Address
〒(zip/postal code) -
(電話番号 Phone Number )
※(注記) If the application information is insufficient, you may be contacted. Please submit your phone number where we can reach you during the daytime.
事務処理記載欄
For official use only
顔写真貼付欄
Attach your ID photo here.
サイズ Size
(縦 4.5c×ばつ横 3.5cm)
(Dimensions 4.5 cm height x
3.5 cm width)
・最近 6 ヶ月以内に撮影
・正面、無帽、無背景のもの
・裏面に、氏名、生年月日を記
入してください。
・Taken less than 6 months prior to
the application submission date.
・Face front portrait, no hat, no
background.
・Write down your name and date of
birth before pasting it on to this
form.