Questionnaire (for application for certificate of eligibility and change)
This questionnaire serves as a reference material in the examination of an application.
Please check or circle (□
レ or ○) the applicable items and be as specific and detailed as
possible when providing written responses. The spouse must complete this questionnaire
independently and without the assistance of any other person.
Any statements in this questionnaire which are found to be contrary to the facts will
prejudice the applicant's examination treatment and may result in criminal charges.
Therefore, please confirm that your answers contain no mistakes before you independently
sign and submit this questionnaire.
[Notes]
* Applicant (your partner) refers to a foreign national subject to examination in order to
enter or stay in Japan (a foreign national wishing to stay in Japan).
* Spouse (you) refers to a Japanese or foreign national married to the applicant.
1. Enter the statuses of the applicant and the spouse. A katakana pronunciation of the
kanji should also be provided for the name of a Japanese national.
Nationality Name Male
Applicant TOPAL FERHAT
TURKEY Female
Name Katakana pronunciation
Nationality PHİLİPPİNES
ANTONİO ROSALİE BATALİA
Address 444-0854 AİCHİ KEN OKAZAKİ SHİ MUTSUNA
HONMACHİ 16-1 SOREYOU 301
TEL Home telephone no. Mobile telephone no.
Residence
0564-83-5712 090-6333-1969
Spouse
Other
□No
/ □Yes (Name(s) )
cohabitants
□ Own house / Rented house
□ Rent 49000 yen 2 LDK
Company AKİ Job description
name FOOD AND BEVERAGES SERVER
Workplace
Address AİCHİ KEN,OKAZAKİ MİNAMİ MİYOU DAİJİ -CHO 4-32 PARK SİDE VİLL 1•FLOOR 104
TEL Date hired
0564-64-6497
2016 YY 9 MM 16 DD
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2. Developments leading to the marriage
(1) Enter the date and place that you first came to know each other and developments
leading to the marriage.
(i) Date: 2021 YY JANUARY MM 4 DD
Place: LEZZET DÜNYASI RESTORANT ,KASUGAİ
(ii) Explain the developments leading to the submission of the marriage registration in
as much detail as possible, citing specific dates from the time that you first met.
If the space provided is insufficient, you may use additional pages as necessary.
You may also attach relevant photos and letters as well as documents proving
international calls.
I FİRST MET MY GİRLFRİEND THROUGH MY GİRLFRİEND’S CAUSİN,MARİE FE ( JUNKO SAN ).
THAT İS ON DECEMBER 18,2020. FOR THE FİRST TİME WE MET WİTH SHE İS FAMİLY AND SHE
DAUGHTER AT THE RESTORANT ( LEZZET DÜNYASI ) İN SPOON MOON. , TO SEE EACH OTHER
İN PERSON, ON JANUARY , 4 , 2021. AFTER THİS DATE, WE CONSTANTLY TEXTED AND VİDEO
CALLED. SECONDLY MET, İN PERSON, WE MET İN KASUGAİ ON JANUARY , 9 , 2021. MY GİRLFRİEND
CAME WİTH HER DAUGHTE R ( YOUKARİ SAN ) . WW WENT TO KARAOKE İN KASUGAİ. WE AGREED
TO BE BOYFRİEND AND GİRLFRİEND ON JANUARY , 14 , 2021. ON THİS DATE, I TOLD MY GİRLFRİEND
ALL ABAUT ME. WE WERE TEXTİNG AND VİDEO CALLİNG EVERDAY AND WE MET İN PERSON SO
MANY TİMES. DURİNG THİS TİME WE DECİDED TO GET MARRİED AND WE MET AGAİN ON APRİL , 24 ,
2021 WİTH MY GİRLFRİEND’S CHİLDREN İN OKAZAKİ. WE TALKED AND DECİDED THAT WE WANTED
TO STAY İN SAME HOUSE WİTH THEİR MOTHER İN KASUGAİ. AFTER THAT, WE SEARCHED FOR
RENTAL HOUSE AROUND KASUGAİ. AND WE FAUND A HOUSE. AFTER JUNE 1 , 2021 WE STARTED
LİVİNG TOGETHER İN THE SAME HOUSE İN KASUGAİ. AFTER THAT , WE VİSİTED HER CHİLDREN
İN OKAZAKİ SO MANY TİMES. USUALLY WE ARE LİVİNG AT THE HOUSE İN KASUGAİ UNTİL
JULY , 3 , 2022.
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(2) Existence of an intermediary
□ No
□ Yes (In the case of marriage arranged by a marriage agency, provide the
agency's name and details below.)
Intermediary
Nationality:
Name: (Male / Female)
Date of birth: YY MM DD
Address:
TEL:
Residence Card No. (for a foreign national)
Date, place and method of introduction
Date: YY MM DD
Place:
Method: □ Photo □ Telephone □ Meeting □ Email
□ Other ( )
Relationship between the intermediary and the applicant (in detail):
Relationship between the intermediary and the spouse (in detail):
* The relationship should be explained in detail, rather than merely stating that the
intermediary is a friend or acquaintance.
3. Language used by the couple
(1) What language do you usually use in conversation with your husband or wife (e.g.,
Chinese, Japanese, etc.)?
(2) What is your mother tongue?
(i) Applicant: TURKİSH
(ii) Spouse: TAGALOG AND ENGLİSH
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(3) To what extent does the applicant understand your mother tongue?
□ Difficult / Need an interpreter □ In writing / Only simple greetings
□ Only everyday conversation □ Fluent
(4) To what extent does the spouse understand the mother tongue of the applicant?
□ Difficult / Need an interpreter □ In writing / Only simple greetings
□ Only everyday conversation □ Fluent
(5) If the applicant understands the Japanese language, provide specifically when and how
he/she learned it.
I DİD SOME ONLİNE LESSONS BY MYSELF FROM TİME TO TİME.
I LEARNED SOME JAPANESE AND ENGLİSH USİNG ONLİNE İNTERNET
TRANLATİON AND WİTH THE HELP OF NY GİRLFRİEND.
(6) When you are unable to make yourselves understood in any language, how do you
communicate?
[Method]: WE GENERALLY UNDERSTAND EACH OTHER. BECAUSE I USE İNTERNET
TRANSLATİON WHEN I CAN’T EXPLAİN MYSELF. ALSO WE COMMUNİCATE WİTH
SİGN OR BODY LANGUAGE.
[If an interpreter was or is being used]
(i) Interpreter's name:
(ii) Interpreter's nationality:
(iii) Interpreter's address:
4. Provide information on the two witnesses who signed your marriage registration in
Japan.
(1) Name: MARİFE CALA, BUENTİPO (Male/Female)
Address: AİCHİ KEN, OKAZAKİSHİ, KAMİ MUTSUNA, 4-5-9 PARKSİDE MİSHİMA B 316
TEL: 080-3638-0786
(2) Name: GÜNDÜZ , EMRAH (Male/Female)
AİCHİ KEN İNAZAWA SHİ NİSHİJİMA SHİNMACHİ , SİEJUTAKU 160 BANCHİ 25 , 102
Address:
TEL: 090-6647-5184
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5. If you held a wedding ceremony (wedding reception), enter the date and location,
etc.
Date: YY MM DD
Location:
Attendants:
Applicant: Father Mother Older brother(s) Younger brother(s)
Older sister(s) Younger sister(s) Children
Spouse: Father Mother Older brother(s) Younger brother(s)
Older sister(s) Younger sister(s) Children
Total number of attendees:
6. Marital history
Applicant: □ First marriage □ Remarriage ( nd/rd/th marriage)
Previous marriage YY MM DD to YY MM DD
(Marriage terminated by □ Legal proceeding (divorce, annulment, etc.)
□ Death of spouse)
Spouse: □ First marriage □ Remarriage ( nd/rd/th marriage)
Previous marriage 1990 YY 01 MM 24 DD to 2003 YY 03 MM 03 DD
(Marriage terminated by □ Legal proceeding (divorce, annulment, etc.)
□ Death of spouse)
7. If the applicant has visited Japan, provide the number of times and periods.
(1) Number of times: FİRST times
(2) Periods Purpose (Sightseeing, job, etc.)
(i) 2019YY 12 MM 07 DD to YY MM DD ( )
(ii) YY MM DD to YY MM DD ( )
(iii) YY MM DD to YY MM DD ( )
(iv) YY MM DD to YY MM DD ( )
(v) YY MM DD to YY MM DD ( )
* Enter the five most recent visits to Japan if the applicant has visited more than five
times.
8. If the spouse has visited the applicant's home country, provide the number of times
and periods.
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(1) Until marriage (from the time you first met) ( times)
(i) YY MM DD to YY MM DD ( )
(ii) YY MM DD to YY MM DD ( )
(iii) YY MM DD to YY MM DD ( )
(iv) YY MM DD to YY MM DD ( )
(v) YY MM DD to YY MM DD ( )
* Enter the five most recent visits to the applicant's home country if the spouse has visited
it more than five times.
(2) After marriage ( times)
(i) YY MM DD to YY MM DD ( )
(ii) YY MM DD to YY MM DD ( )
(iii) YY MM DD to YY MM DD ( )
(iv) YY MM DD to YY MM DD ( )
(v) YY MM DD to YY MM DD ( )
* Enter the five most recent visits to the applicant's home country if the spouse has visited
it more than five times.
9. Has the applicant ever been forcibly deported from Japan (including under a
departure order)?
□ No
□ Yes ( times)
10. For an applicant answering in the affirmative to Question 9 above
(1) Details of the violation
□ Illegally stayed beyond the period of stay (Overstay)
□ Illegal entry (via smuggling, use of fake passport, etc.)
□ Other ( REFUGEE’S VİSA )
(2) Date and airport of most recent deportation
Date: YY MM DD from Airport
(3) Are the nationality, name and date of birth stated in this application the same as those
stated in the applicant's passport at the time of his/her most recent deportation?
□ Same
□ Different name, etc. Nationality:
Name:
Date of birth: YY MM DD
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(4) If you had lived together with your spouse in Japan before his/her deportation, enter
said period and address.
Period: YY MM DD to YY MM DD
Address:
11. Relatives of the applicant and the spouse
* Provide telephone numbers of relatives residing in Japan if possible. If your parents
have passed away, enter "Deceased" in the address column. Enter information about
your children in table (2) below. If you do not have any children, enter "None."
(1) Enter information about your parents, brothers and sisters.
Relationship Name Age Address TEL
[Example]
Father Taro Nyukan 62 1-2-301, ××, Chiyoda-ku, Tokyo 03-▽△-××××
TOPAL
Father MUSTAFA 70 ADIYAMAN ,TURKEY 0534-066-4902
Mother
Husband's relatives
STEP TOPAL
İSLİM 55 ADIYAMAN , TURKEY 0536-381-2150
MOTHER
ELDEST TOPAL ADIYAMAN , TURKEY 0531-562-9921
BROTHER MEHMET 41
SECOND GÜNDÜZ AİCHİ KEN İNAZAWA SHİ NİSHİJİMA SHİN 090-6647-5184
COUSİN EMRAH MACHİ , SİEJUTAKU 160 BANCHİ 25 , 102
[Example]
Father Nyukan James V. 62 New York, U.S.A (city name) ××××-12-○○-345
Father
74 985 SİTİO MALİNDİG SAN MİGUEL
PARRO
Mother ROSALİNA
09690917538
CALUMPİT BULACAN
YOUNGER
Wife's relatives
ANTONİO 985 SİTİO MALİNDİG SAN MİGUEL
51 09982426422
SİSTER MARLYN CALUMPİT BULACAN
ANTONİO AİCHİ KEN OKAZAKİSHİ MUTSUNA
DAUGHTER YOUKARİ
20 HONMACHİ 16-1 SOREYOU 301 080-6973-2123
ANTONİO AİCHİ KEN OKAZAKİSHİ MUTSUNA NONE
SON YOUTAKA REY 19 HONMACHİ 16-1 SOREYOU 301
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(2) Enter information about your children.
Relationship Name Date of Birth Address
[Example]
Husband's Saburo Nyukan Nov. 19, 1975 9-8-7, ××, Saitama-shi, Saitama
eldest son
Wife's eldest Nyukan Mary C Dec. 15, 1999 New York, U.S.A (city name)
daughter
WİFE ANTONİO AİCHİ KEN OKAZAKİSHİ MUTSUNA
Jan. 21, 2002
DAUGHTER YOUKARİ HONMACHİ 16-1 SOREYOU 301
ANTONİO AİCHİ KEN OKAZAKİSHİ MUTSUNA
WİFE SON
YOUTAKA REY
FEB. 03, 2003 HONMACHİ 16-1 SOREYOU 301
12. Which of your relatives know of the marriage? (Circle all applicable relatives)
Husband's side: Father Mother Older brother(s) Younger brother(s)
Older sister(s) Younger sister(s) Children
Wife's side: Father Mother Older brother(s) Younger brother(s)
Older sister(s) Younger sister(s) Children
The above statements contain no mistakes.
YY MM DD
Signature (Spouse):
(NOTE)
Any statements in this questionnaire which are found to be contrary to the facts will
prejudice the applicant's examination treatment and may result in criminal charges.
Therefore, please confirm that your answers contain no mistakes before you independently
sign and submit this questionnaire.
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