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VISA

This document is a visa application form for entering Japan, filled out by Malaka Lakshan Samarakoon Withana Arachchillage, a Sri Lankan national. The applicant intends to stay in Japan for 1 year and 3 months for educational purposes at Numazu Japan Language College, arriving on March 30, 2025. The form includes personal details, passport information, and a declaration of the truthfulness of the provided information.

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2 views

VISA

This document is a visa application form for entering Japan, filled out by Malaka Lakshan Samarakoon Withana Arachchillage, a Sri Lankan national. The applicant intends to stay in Japan for 1 year and 3 months for educational purposes at Numazu Japan Language College, arriving on March 30, 2025. The form includes personal details, passport information, and a declaration of the truthfulness of the provided information.

Uploaded by

wmdr2jpsrh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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VISA APPLICATION FORM TO ENTER JAPAN

(Paste photo here)

45mm ×35mm
Official use only
or 2in x 1.4in

Surname (as shown in passport) WITHANA ARACHCHILLAGE


Given and middle names (as shown in passport) MALAKA LAKSHAN SAMARAKOON
Other names (including any other names you are or have been known by)
N/A
Date of birth 10/10/2004 Place of birth KEGALLE SABARAGAMUWA SRI LANKA
(Day)/(Month)/(Year) (City) (State or Province) (Country)
Sex: Male Female Marital status: Single Married Widowed Divorced
Nationality or citizenship LKA
Former and/or other nationalities or citizenships N/A
ID No. issued to you by your government 200428404034
Passport type: Diplomatic Official Ordinary Other Passport No. N11478775
Place of issue COLOMBO Date of issue 12/07/2024
(Day)/(Month)/(Year)
Issuing authority DEPARTMENT OF IMMIGRATION AND EMIGRATION Date of expiry 12/07/2034
(Day)/(Month)/(Year)
Certificate of Eligibility No. P 24-036492
STUDENT
Purpose of visit to Japan/Status of residence
Intended length of stay in Japan 1 YEAR & 3 MONT Date of arrival in Japan 30 MARCH 2025
Port of entry into Japan NAGOYA Name of ship or airline CHINA EASTERN AIRLINES
Names and addresses of hotels or persons with whom applicant intends to stay
Name NUMAZU JAPAN LANGUAGE COLLEGE Tel. +81-55-939-6590

17-1 SAIJOCHO, NUMAZU-CITY, SHIZUOKA 410-0804, JAPAN


Address
Dates and duration of previous stays in Japan N/A
Your current residential address (if you have more than one address, please list them all)

"AJANTHA" ALPITIYA, GALAPITAMADA


Address
Tel. N/A Mobile No. +94716942471
E-Mail [email protected]
Current profession or occupation and position N/A
Name and address of employer

Name N/A Tel. N/A

N/A
Address
(Note)Partner's profession/occupation (or that of parents, if applicant is a minor):
N/A
Guarantor or reference in Japan(Please provide details of the guarantor or the person to be visited in Japan)
Name NUMAZU JAPAN LANGUAGE COLLEGE Tel. +81-55-939-6590

17-1 SAIJOCHO, NUMAZU-CITY, SHIZUOKA 410-0804, JAPAN


Address
Date of birth N/A Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant PRINCIPAL OF SCHOOL
Profession or occupation and position N/A
Nationality and immigration status N/A
Inviter in Japan(Please write 'same as above' if the inviting person and the guarantor are the same)
Name SAME AS ABOVE Tel. SAME AS ABOVE

SAME AS ABOVE
Address
Date of birth SAME AS Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant SAME AS ABOVE
Profession or occupation and position SAME AS ABOVE
Nationality and immigration status SAME AS ABOVE
(Note)Remarks/Special circumstances, if any N/A
Have you ever:
● been convicted of a crime or offence in any country? Yes No
● been sentenced to imprisonment for 1 year or more in any country?(Note 2) Yes No
● been deported or removed from Japan or any country for overstaying your visa or violating
any law or regulation? Yes No
● been convicted and sentenced for a drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances?(Note 2) Yes No
● engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
persons, or in the provision of a place for prostitution, or any other activity directly
connected to prostitution? Yes No
● committed trafficking in persons or incited or aided another to commit such an offence? Yes No
(Note 2) Please tick “Yes” if you have received any sentence, even if the sentence was suspended.
If you answered “Yes” to any of the above questions, please provide relevant details.

“I hereby declare that the statement given above is true and correct. I understand that immigration status and period of stay to
be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not
entitle the bearer to enter Japan upon arrival at port of entry if he or she is found inadmissible.”
“I hereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing
my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the
Japanese embassy/consulate-general, when such payment is necessary.”

Date of application Signature of applicant


(Day)/(Month)/(Year)
(Note)It is not mandatory to complete these items.

Any personal information filled in this application form as well as additional personal information submitted for the visa
application (hereinafter referred to as "Retained Personal Information?) will be handled appropriately by the Ministry of Foreign
Affairs of Japan (including Japanese overseas establishments) in accordance with the Act on the Protection of Personal
Information (Act No. 57 of 2003, hereinafter, ?the Act?). Retained Personal Information will only be used to the extent necessary
for the purpose of processing the visa application (including providing personal information to the transportation company
which you are going to travel with, or the alternative transportation company which you are going to travel with due to
unforeseen circumstances), immigration control, international cooperation and for other purposes in compliance with Article 69
of the Act.

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