Application form (English) - インターカルト日本語学校

学生募集要項
Applicaton Guide
孃伏酒嫗
俳持乞増推悪
インターカルト日本語学校
１
Entrance Qualifications
・An applicant must be more than a high school graduates or holding those of qualifications.
・An applicant planning seeking qualification in Japanese for further education in Japan must have
completed 12 years or more educational curriculum.
・An applicant who have passed the 4th level of the Japanese language proficiency test or holding those
of equal qualifications.
・An applicant is qualified to apply within the range of 3 years after the latest graduation.
Courses and study terms
Admission
2
Preparatory Course
【Shinanomachi-school】
General Course
【Koenji-school】
3
Courses
Admission
Courses
April
one year/two years
course
October
One and a half
year course
July
one year and nine month
course
January one year and three month
course
Application accepted
September 1 ～the end of September
January 1～the end of January
March １～the end of March
July 1～the end of July
Admission in April
Admission in July
Admission in October
Admission in January
*Please confirm the deadline.
4
Schedule of classes
Monday through Friday (5days a week) 1class=50 minutes
Morning (Advanced and Intermediate classes)
Afternoon (Intermediate and Beginner’s classes)
5
Tuition Fee and Other Costs
The due date
Screening fee
Admission fee
Activity fee
Facility
Maintenance fee
Student Society
Entrance fee
First half of
Tuition fee
Second half of
Tuition fee
Activity fee
Facility
Maintenance fee
Student Society
Entrance fee
First half of
Tuition fee
Second half of
Tuition fee
Total
Class schedule
09:20～13:05
13:25～17:10
（except textbook）
1 year
Course
1 year 3
month
course
1 year 6
month
course
1 year 9
month
course
2 year
Course
\20,000
\50,000
\20,000
\50,000
\20,000
\50,000
\20,000
\50,000
\20,000
\50,000
\30,000
\40,000
\15,000
\30,000
\30,000
\20,000
\25,000
\10,000
\20,000
\20,000
Upon Certificate of
Eligibility Issuance
\8,000
\11,600
\11,600
\8,000
\8,000
Upon Certificate of
Eligibility Issuance
\282,000
\282,000
\282,000
\282,000
\282,000
\282,000
\282,000
\282,000
\282,000
---
---
\30,000
\30,000
\30,000
---
---
\20,000
\15,000
\20,000
Prior to start of
second year
---
---
---
\8,000
\8,000
Prior to start of
second year
---
\141,000
\282,000
\282,000
\282,000
Prior to start of
next term.
---
---
---
\141,000
\282,000
\851,600
\1.002,600
\1,168,000
\1,314,000
Upon Application
Upon Application
Upon Certificate of
Eligibility Issuance
Upon Certificate of
Eligibility Issuance
Upon Certificate of
Eligibility Issuance
prior to start of
next term.
Prior to start of
second year
Prior to start of
second year
\692,000
\282,000
・If an applicant is qualified for the one year and nine month course, the second due date for the tuition
fee is the next year July (the second July).
・The above fees do not include textbooks.
・Under the Japanese law, unless all students are required to participate in international student
cooperative societies, all students must join the National Health Insurance System.
6
Education and Immigration Application Costs
(a) Upon Application
At time of application, please pay Admission fee; and Screening fee.
(b) Upon Certificate of Eligibility Issuance by Japanese Immigration
At time Certificate of Eligibility Issuance by Japanese Immigration, please pay a 6 months school Tuition
fee; Activity fee; Facility Maintenance fee; and Student Society Entrance fee.
•
In the event of the Certificate of Eligibility not being issued, the Admission fee will be refunded.
•
In the event of the Visa application not being accepted by Foreign Embassies, the Admission
fee; the 6 months school Tuition fee; the Activity fee; the Facility Maintenance fee and Student
Society Entrance fee will all be refunded. Note that the Screening fee will not be refunded.
Please note that proof of the Embassy’s non-acceptance of your visa is required in this outcome.
In the event of a withdraw of entry to the school for personal reasons before you come to Japan –
even if you have received your visa from the Embassy – the 6 months school Tuition fee; the
Facility Maintenance fee and Student Society Entrance fee will all be refunded. Note that the
Admission fee and Screening fee will not be refunded. Please note that proof of your visa
cancellation is required in this outcome.
(c) Upon Arrival in Japan
•
For the first six months after you arrive in Japan, the following fees are non refundable in any
circumstances (e.g. returning home, change of visa conditions) should you wish to resign from
the school: 6 months school Tuition fee; Activity fee; Facility Maintenance fee; and Student
Society Entrance fee.
•
After the first six months after, should you wish to resign from the school under certain
circumstances (e.g. returning home, change of visa conditions), please consult with local staff
concerning refund of the 6 months school tuition fee
•
Once the school term has started the following annual fees are not refunded: Activity fee;
Facility Maintenance fee; and Student Society Entrance fee.
7
National Health Insurance System
Under the Japanese law, a person who stays in Japan more than one year must join the National Health
Insurance System.
This insurance covers 70% of the medical fees, assuming the participant pays the remaining 30% of the
medical fees.
After you have completed the Certificate of Eligibility, you can complete the Alien Registration process
at your local City Hall. Also, you can complete the National Health Insurance System application at local
City Hall.
In addition, please note that you are required to join a Student Society while you are a student of our
school. This society will provide precautions against unexpected events during your attendance of our
school.
8
1.
2.
3.
4.
Notes
This school does not accept direct mail applications from overseas. Students must have a local
guarantor who is a resident of Japan and who can support the applicant once they come to Japan.
Please ask your guarantor to complete this application procedure.
Overseas issued documentation must be accompanied by a Japanese language translation. Also, if the
original documentation is not in English, Chinese or Korean, then an English language translation
must be provided.
All submitted documentation would not be returned to the applicant. However, an original
graduation certification will be returned once the application for Certificate of Eligibility has been
completed.
Each of the aforementioned fees is subject to change, so please confirm the fees directly with the
school in advance.
5. Students who wish to undertake part-time employment while they are in Japan should obtain
approval from the Immigration Office. Accepted applicants can work four hours per day, although
there are a limited number of job types available.
9
The Procedures for entering this school
①
②
Inter-Cultural
Instituted of Japan
Local Guarantor
Or Overseas
⑥
⑤
Applicant
Application for status of
⑧
⑦
Residence as a student
④
Japanese Embassy
Tokyo Immigration
Office
③
Documents to be submitted
10
1. Documents which an applicant prepares
Necessary documents
Notes
① 8 photographs
4 ×3 cm, which were taken within the last 6 months
② Personal history
You (an applicant) must fill in the specified form by yourself.
(You must write all your educational background and work experiences.
Please write so, if you prepared for an entrance examination for a while or
served in the army.)
③ Certificate of graduation
You (an applicant) must prepare a certificate of graduation Oran original
diploma of the final school. If you are an under-graduate (or under leave
of absence from school), or leave college before graduation, you must
prepare a certificate of graduation or an original diploma of the high school.
◎Please have your elementary school documents such as eligibility and
graduation evidence ready if the date you entered the elementary school
does not correspond to your own country educational system.
④Japanese proficiency certificate
For those who have passed the 4th level of Japanese Language Proficiency
Test or hold a similar qualification, you have to at least completed 150
hours of Japanese study in order to be qualified upon the date of issuing the
document. Also, you have to pass the 4th level of Japanese Language
Proficiency Tests even though you have satisfied the 150 hours minimum
requirement.
⑤ Residential Status Record
If you are the People Republic of China passport holders; copies of Resideentail Status Record issued by the Chinese Police Department is required.
The copies need to clearly record the applicant educational background
and occupational status.
⑥ Certificate of occupation
Applicant who graduated more than 5 years will be carefully screened.
⑦ The copy of passport
The copy of your passport if you already possess a passport
⑧ Other documents
Others (if you are requested to submit from the Immigration Bureau)
2. Documents concerning a payer who pays school and living expenses for an applicant
(Please choose one case among A and B)
A. In case a payer lives in a country other than Japan, a payer prepares the following.
Necessary documents
① Letter of guarantee
to pay expenses
② Relationship certification
Notes
A payer should write by himself/herself in the form prescribed by the
Immigration Office.
An applicant must submit the relationship certificate with the sponsor.
(notary public)
③Residential Status Record
If you are the Peoples’ Republic of China passport holders; The copies need
to clearly record of financial sponsor’s educational background and occupa
tional status.
④Certificate of the balance of a do A clearly stated banking record and bank account number is required.
cument
It is important that the amount recorded on your bank statement is
sufficient enough to support your living costs in Japan. It has to be
enough to support the entire duration of your learning time in Japan.
⑤ Fixed Deposit Receipt in
Foreign Currency
For the Peoples’ Republic of China passport holders, you must submit
c
opies of your banking and money depositing records to provide financial e
vidence.
⑥The copy of a passbook
Copies of applicant’ banking and money deposit records are required in
order to prove that you have normal financial activities such as money
deposits or withdrawals from your host bank.
⑦ Certificate of occupation
Employment and income related documents have to show the nature of
continuity and stability. In other words, an applicant cannot have a jobless h
istory for any long period of time.
・A letter of employment is required from your employer.
・A self-employed financial sponsor needs to submit his/her business
certificate or license.
⑧ Certificate of income
Please submit the most recent income report up to the past 3 years.
A salary report issued by the applicant’ employer is required. If the amount
of the applicant’ actual salary does not match his/her bank deposits record,
the application will not be accepted.
⑨ Certificate of local taxation
All income related documents have to be issued by the Revenue Service
and associated officials.
◎ An income tax certificate is required from applicant’s employer.
◎ Self-employed applicants need to have an income tax report and receipt i
ssued by the Revenue Service in order to be recognized.
⑩ Other documents
Others (if you are requested to submit from the Immigration Bureau)
B. In case a payer lives in Japan, a payer prepares the following.
Necessary documents
Notes
① Letter of guarantee
A payer should write by himself/herself in the form prescribed by the
Immigration Office. （Please use a legal seal）
to pay expenses
②Residential Status Record
Resident’s card which shows a whole family or Certificate of Alien
Registration.
③Relationship certification
If you are the Peoples’ Republic of China passport holders; The copies of R
esidential Status Record issued by the Chinese Police Department is
re
quired.
④Certificate of the balance of a do A clearly stated banking record and bank account number is required.
cument
is important that the amount recorded on your bank statement is sufficient
enough to support your living costs in Japan. It has to be enough to support
the entire duration of your learning time in Japan.
⑤ The copy of a passbook
Applicants have to submit his/her bank account’ transaction history with
in-and-out/deposit and withdrawal detail to support their application.
⑥ Certificate of occupation
Employment and income related documents have to show continuity and
stability. In other words, an applicant cannot have a jobless history for long
periods of time.
・A letter of employment is required from your employer. Company
Executives need to submit their business certificate.
・Self-employed applicants need to submit a duplicate of your business
certificate.
⑦ Certificate of income
Please submit the most recent total income report and income tax record up
to 3 years (residential tax report).
⑧ Certificate of Seal Impression
Please use a legal seal for the sealing column of a cost payment document.
⑨ Other documents
Others (if you are requested to submit from the Immigration Bureau)
3. Letter of Agreement
The person who is responsible to an applicant for living and studying in
Japan must write this Letter of Agreement for our school.
11 School Map
Ikebukuro
Ueno
ＪＲ Chuo・Sobu Line
ＪＲ Sobu Line
Shinjuku
Chiba
Akihabara
Ochanomizu
Nakano
Shinanomach
Koenji
Shibuya
Tokyo
KOENJI SCHOOL
for
Mitaka
Koenji Station
JR
Chuo
Line
for Shinjuku
Tokyu
Store
South
Exit
Location ：
4-44-6，koenji-nami，
Suginami-ku,Tokyo
（About 1 minute walk
from Koenji Station）
Chuo-Seminar
Mitsui Sumito Bank
Hikawa
Shrine
SHINANOMACHI SCHOOL
Keio Unv.Hospital
Shinanomachi
Station
For Yotsuya
MINI STOP
a barber shop
Location ：
12-2，Minami-motomachi，
Shinjuku-ku,Tokyo
（About 6 minutes' walk
from Shinanomachi Station）
Sen-nichidani kaido(Hall)
A foot
bridge
Shinanomachi
School
Mejikinenkan
a ticket barrier
Mizuho
Bank
a ticket
office
Park
Sennichizaka
Slope
in the directon
Tokyoa telephone
of Keio
Mitsubishi Bank
a fluit
shop
Entrance of
Station building
in the direction Vending
of the School
machine
Newdays
a taxi stand
希望する課程（　校　舎　名　）
総合進学課程
進　学　課　程
□ General Course □ Preparatory Course
（高円寺校 Koenji）
登録番号
授業開始日
０
２０
1
月
ＰＨＯＴＯ
Malaysian
Lee Ching Ho
氏名：
( Nationality )
４ｃｍ×３ｃｍ
sample
履　歴　書
( PERSONAL RECORDS )
1. 国籍：
年
（信濃町校 Shinanomachi）
( Name )
氏名：
( Name Ａｌｐｈａｂｅｔ　）
１９　81 年
2. 生年月日：
( Date of Birth )
( Year )
3. 現住所：
6
月
( Month )
4
日
性別： □ 男・ □女
( Day )
( Sex )
( Male ) ( Female )
電話番号：
888 Kampung Bharu, Selangor, Darul Ehsan, West Malaysia
( Present Address )
603-123-4567
( Telephone number )
ditto
4. 本籍地住所：
( Permanent Address )
5. 配偶者の有無：
( Marital status )
□ 無　・　□有
（配偶者氏名
( Single ・ Married )
出生地：
Selangor, Darul Ehsan
( Place of Birth
West Malaysia,Malaysia
）
( Name of spouse )
※ 以下の6.7.については、初等教育入学から現在まで、空白の期間が一切無いよう、全て記入すること。
※
The following 6. and 7. you should fill in up all the blanks from elementary school till now.
6. 学歴：（初等教育から順次最終学歴まで全て記載すること）
Education Record : ( from an elementaly school to the last highest school attended )
学　校　名
所
( Name of School )
（3）
（4）
UNIVERSITY OF MALAYSIA
（2）
地
修学期間
入学年・月
( Address )
S.R.J.K.
S.M.SERI GARING
S.M.SERI GARING
（1）
在
987 Kindang, Selangor
40299 Pawang, Selangor
40299 Pawang, Selangor
123 Central Road, K.L.
（5） (temprary absence from school)
( Date of Admission )
Year
Month
87
93
96
99
01
年
年
年
年
年
9
9
9
9
9
( Period of Study )
卒業年・月
( Date of Graduated )
Year
Month
月
～
月
～
月
～
月
～
月
～
93
96
99
04
04
年
年
年
年
年
7
7
7
7
7
月
月
月
月
月
（6）
年
月
～
年
月
（7）
年
月
～
年
月
7. 職歴、兵役等： Occupation History : ( Write experience of employment in order of date of employment )
勤　務　先　名
職種
所　在　地
就職年・月
( Name of Company )
（1）
( Occupation )
CHONG TAK PO CO.LTD.
( Address )
04
456 Southern Rd. K.L.
Engineer
退職年・月
( Date of Employment )
Year
Month
年
8
( Date of Resignation )
Year
Month
月
～
年
月
（2）
年
月
～
年
月
（3）
年
月
～
年
月
（4）
年
月
～
年
月
8. 日本語学習歴： Experience in studying Japanese
学　校　名
所
( Name of School )
在
修学期間
入学年・月
地
( Address )
（1）
UNIVERSITY OF MALAYSIA
（2）
Fuji Japanese Sentre
( Date of Admission )
Year
Month
99
04
123 Central Road, K.L.
456 Southern Road, K.L.
（3）
年
年
年
9
9
( Period of Study )
卒業年・月
( Date of Graduated )
Year
Month
01
～
月
～
年
月
月
～
年
月
年
9. 日本語学校修了後の予定：My plan after graduation from this school
(　)
Science University of Tokyo (Tokyo Rika Daigaku)
進学希望進学希望先学校名
Go to university or college
Name of school
希
望
科
目
Graduate school fo Engineering Industrial Chemistry
Name of major subject
(　)　帰　国　□　就業　□　復学　□　その他
Return home
(　)　その他　Others
Work
Return to School
Others
7
月
月
10.パスポートの有無および来日歴
Passport and Experience of visiting Japan
sample
パスポートの有無： □ 有　Yes ・ □ 無 No
Do you have a passport?
987123
パスポート番号：
05 年 2 月 1 日有効期限： 10 年 2 月 1 日
発行年月日
Passport　No.
Date of Issue
来　日　歴： □ 有　Yes
1
Year
回数　Times
Month
・
Day
Date of Experience
Year
Month
Day
□ 無 No
Experience of visiting Japan
日本への入出国歴：（すべて記載すること）If you have experience in
入国年月日
出国年月日
( Date of Entry )
Year
（1）
Day
Year
3 月 15 日～
年
在留資格
( Date of Leave )
Month
04
entering and leaving Japan, please write them below.
04
年
Month
入国目的
( Status of stay in Japan )
( Purpose of entry )
Day
3 月 22 日
（2）
年
月
日～
年
月
日
（3）
年
月
日～
年
月
日
（4）
年
月
日～
年
月
日
（5）
年
月
日～
年
月
日
（6）
年
月
日～
年
月
日
Temporary Visit
Sightseeing
11.家族に関する事項
Family snd Relative
Lee Kok Meon
父親氏名：
Father's name
生年月日： 19
父親住所：
Yeong Siu Hang
母親氏名：
生年月日： 19
3
月
27
日
Day
Month
52
年
Year
Date of birth
母親住所：
年
職業：
economist
Occupation
888 Kampung Bharu, Selangor, Darul Ehsan, West Malaysia
Father's address
Mother's name
50
Year
Date of birth
5
月
8
日
Day
month
職業： house
wife
Occupation
888 Kampung Bharu, Selangor, Darul Ehsan, West Malaysia
Mother's address
兄弟姉妹の有無　有 Yes　・　無 No
（
Brother
）氏名：
Relationship
（
Sister
）氏名：
Relationship
（
Lee Tien Sang
Name
Lee Muoi Far
Name
）氏名：
Relationship
Name
）氏名：
（
Relationship
生年月日： 19
Name
85
生年月日： 19
88
生年月日： 19
年
4
年
生年月日： 19
月
日
Day
日
Day
職業： High School Student
職業：　Occupation
月
日
Day
month
職業： University Student
Occupation
月
年
日
Occupation
1
月
month
Year
9
Day
month
Year
Date of birth
9
month
Year
Date of birth
Date of birth
年
Year
Date of birth
職業：　Occupation
12 経費支弁者が父母以外の場合記入してください。
Fill in if your guarantee is not your parents
経費支弁者氏名：
生年月日：１９　Guarantee's name
Father's birthday
経費支弁者住所
Guarantee's address
年
year
電話番号：
Phone No.
月
month
日
day
sample
13. 日本語学習理由：（日本語を学ぶ目的を具体的かつ簡潔に述べること）
Purpose of Studying Japanese. Give the reason concreately and concisely.
申請者氏名：
( Name )
Lee Ching Ho
経費支弁書
Letter of guarantee to pay expenses
sample
日本国法務大臣殿
To the Minister of Justice
国
Malaysian
籍
（ Nationality ）
Lee Ching Ho
学生氏名
（Student Name ）
1981
生年月日
（ Date of Birth ）
６
年
(Year )
4
月
( Month )
（男
女）
( Male
Female )
日
( Day )
私は、この度上記の者が日本国に在留中／入国した場合の経費支弁者になりましたので、下記のとおり経費支弁の
引受け経緯を説明するとともに、経費支弁について誓約します。
I became guarantee to pay expenses for the above-mentioned person during his / her stay / enter in Japan. I hereby
pledge that I will bear the expenses in following manner, with explanation of reason for being guarantee to pay
1.
経費支弁の引受け経緯（申請者の経費の支弁を引受けた経緯及び申請者との関係について具体的に記載してください。）
Reason for being guarantee to pay expenses (Please write concretely, about the details to guarantee to pay
applicant, and about relationship with the applicant.)
I will bear all the expensese of school fees snd living costs in order that my son may
devote himself to study Japanese in Japan.
2. 経費支弁内容
Contents to pay expenses
私は、上記の者の日本国滞在について、下記のとおり経費支弁することを誓約します。
また、上記の者が在留期間更新申請を行う際には、送金証明書又は本人名義の預金通帳（送金事実、経費支弁事実が記載さ
れたもの）の写し等で、生活費等の支弁事実を明らかにする書類を提出します。
I hereby pledge that I will bear expenses of the above-mentioned person during his/her stay in Japan in the following manner.
Moreover, when applying for extension of period of stay, documents to prove the ability of covering the living and other
such as copy of the Certificate of Remittance or Bankbook in the name of the applicant himself / herself will be submitted.
記
（１）学
費（Tuition）
年間（Per year）
内　訳
Details
（２）生活費（Living Expenses）月
選　考　料
入　学　金
授　業　料
その他費用
(Screening fee)
(Admission fee)
(Tuition fee)
(Others)
700,000
円
20,000
50,000
564,000
66,000
円
円
円
円
110,000
額 (Per Month）
円
＊　資格外活動予定の有無　（　）有　（　）無
Do you intended to work part-time?
Yes
No
有の場合、資格外活動開始予定日　（　）入学直後　（
If yes, when do you plan to start
3
Immediately after coming course
予定収入金額　（
6　Expected income from part-time job
）ヶ月後
months after
）万円／月
yen/per month
（３）支弁方法（送金・振込み等支弁方法を選んでください。複数選択可）
How will you pay for the course? (Please choose from the following methods:)
（　）申請者負担　（　）外国からの送金　Self
（　）外国からの携行
Remittance from outside Japan
Bring payment with you to Japan
（　）資格外活動による収入　（　）奨学金
Income of part-time job
Scholarship
＊　来日後の居住先
Place you are planning to live;
（　）インターカルト日本語学校学生寮　（　）民間学生寮（　）民間ｱﾊﾟｰﾄ（ﾏﾝｼｮﾝ）
Dormitory for students
Private company's Dormitor
Apartment/Flat
（　）友人宅（　名と同居）　（　）在日親族宅
Friend's house
Number of roommates
Family or Relative's house
２０
住
所 888 Kampung Bharu, Selangor, Darul Ehsan, West Malaysia
（ Address ）
氏
名
（ Name ）
０6 年
(Year )
電話番号
7月
( Month )
010-8888-8888
( Telephone Number ）
Lee Tien Sang
実印　学生との関係
Father
（ Stamp or Signature ）( Relationship with the applicant ）
1 日
( Day )
就学同意書
（ AGREEMENT 昼俳疑税辞）
sample
インターカルト日本語学校校長　殿
Lee Ching Ho
学生氏名
( Student Name 俳持失誤僥伏侖兆 )
1981 年
生年月日
( Birth Day 持鰍杉析伏晩 )
国
4 日
６月
（ Year 鰍 ) ( Month 杉 )
( Day 析 )
Malaysian
籍
( Nationality 厩旋忽汐 )
私は、上記学生が日本で就学することに同意します。また、私は上記の者が就学を許可さ
れ、入学した後は、本人の日本における行動と金銭上の義務について、支弁者とともに一切
の責任を負います。
I agree to his/her going to Japan to study, I shall also assume any and all responsibilities for the above
student for his /her behavior and financial obligations while he/she is in Japan, after he/she is admitted to
the Inter-Cultural Institute of Japan.
沙昔精雌奄俳持戚析沙拭辞昼俳馬澗依聖疑税杯艦陥. 暁廃沙昔精雌奄俳持戚昼俳買亜研閤焼辞
脊俳廃板析沙拭辞馬澗楳疑引榎穿旋昔庚薦拭企馬食走災切人敗臆析端税奪績聖走畏柔艦陥.
厘揖吭貧峰僥伏壓晩云祥僥｡旺斤凪云繁函誼秘僥俯辛朔,壓晩云議僥楼豚寂坪,購豢侭嗤議倖繁佩葎才署熱貧
恂畠幡吶暦貧減匯俳夭販｡
Lee Tien Sang
同意者氏名
( Name of person who agrees. 疑税切失誤. 揖吭宀侖兆 )
年
50
齢　歳
本人との関係
Father
( Age 尻敬定槍 )
( Relationship between the student and you. 沙昔引税淫域嚥僥伏購狼 )
自宅住所
888 Kampung Bharu, Selangor, Darul Ehsan, West
( Adress 切澱爽社徭姙廖峽 )
010-8888-8888
自宅電話番号
( Phone No. 切澱穿鉢腰硲徭姙窮三催鷹 )
職
economist
業
( Occupation 送穣岼匍 )
勤務先名称
U.S.35000
年　収
（Annual Income 鰍呪脊年収入）
BIG WORLD COMPANY L.T.D.,
( Place of work 悦巷坦誤暢販岼巷望/汽了兆各 )
勤務先住所
89 Pawang, Selangor, Darul Ehsan, West Malaysia
( Adress of working place 悦巷坦爽社販岼巷望/汽了廖峽 )
勤務先電話番号
010-4444-4444
( Phone No.悦巷坦穿鉢腰硲販岼巷望/汽了窮三催鷹 )
日付
( Date 析獣晩豚 )
署名
( Name 辞誤侖兆 )
2006 年
7月
1 日
（ Year 鰍 ) ( Month 杉 )
( Day 析 )
Lee Tien Sang
印
( Signature 昔姶固嫗 )

Download Report