Application form TOP Application form 【Contractor】 Application NumberRequired NameRequired Name（Katakana）Required Name（Chinese Characters）Optional Date of BirthRequired --- 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year --- 1 2 3 4 5 6 7 8 9 10 11 12 Month --- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day SexRequired Male Female Current AddressRequired Phone NumberRequired Email AddressRequired Visa TypeOptional Student Working Designated Activities Tourist Others Reason for Moving Optional Education Work Others Emergency Contact：Parent in your home country (father or mother) NameRequired Date of BirthRequired --- 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year --- 1 2 3 4 5 6 7 8 9 10 11 12 Month --- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day RelationshipRequired -- Father Mother Sibling Relative Others SexRequired Male Female Current AddressRequired Same as contractor Phone NumberRequired Email AddressRequired 【Optional Services】 Purchase Futon(9,000円)Optional Need Not Needed Purchase daily necessities setOptional Need Not Needed Purchase Inkan (1,000円)OptionalCharacter on Inkan (Max. 3 character) Need Not Needed No request Request 【Identity confirmation】 ※Please limit the total picture size to 15MB or an error will occur. Picture 1 (Picture of applicant’s face)Required × Click here or drag the photo. × Picture 2 (see the) following tablesRequired × Click here or drag the photo. × Picture 3 (see the) following tablesRequired × Click here or drag the photo. × For customers currently residing in Japan(Either No. 1 or 2) 1.Residence Card Front and Back side photo 2.Japan Driving License Front and Back side photo For customers currently residing abroad (Both are required) 1.Passport Photo Page photo 2.Certificate of Eligibility（COE） Request for electricity / gas opening application after receiving and accepting the explanation of the important matter explanation of 'Electricity supply and demand contract' About electric gas application service Agree to our privacy policy About our privacy policy 仮申込期間は約1週間となります。お申込内容により、お受けできない場合がございます。予めご了承くださいませ。詳細は担当者より連絡いたします。 ※同じお客様から2度以上のお申込を頂いた場合、直近の内容を優先いたします RapidSSLを使用して、お客様の個人情報を保護しています。 httpsで始まるアドレス上ではすべての情報がSSLで暗号化されてから送受信されます。
