diff --git a/request_form.php b/request_form.php
new file mode 100644
index 0000000..86bc7b4
--- /dev/null
+++ b/request_form.php
@@ -0,0 +1,147 @@
+<?php
+require_once __DIR__ . '/auth_check.php';
+
+$pageTitle = "Program Change Request Form";
+$username = $_SESSION['username'] ?? 'User';
+$full_name = $_SESSION['full_name'] ?? '';
+$department = $_SESSION['department'] ?? '';
+
+?>
+<!DOCTYPE html>
+<html lang="en">
+<head>
+    <meta charset="UTF-8">
+    <meta name="viewport" content="width=device-width, initial-scale=1.0">
+    <title><?= htmlspecialchars($pageTitle) ?></title>
+    <link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.5.2/css/bootstrap.min.css">
+    <link rel="stylesheet" href="assets/css/custom.css">
+</head>
+<body>
+    <?php include 'header.php'; ?>
+
+    <div class="container mt-3">
+        <?php if (isset($_SESSION['success_message'])): ?>
+            <div class="alert alert-success alert-dismissible fade show" role="alert">
+                <?= htmlspecialchars($_SESSION['success_message']); ?>
+                <button type="button" class="close" data-dismiss="alert" aria-label="Close">
+                    <span aria-hidden="true">&times;</span>
+                </button>
+            </div>
+            <?php unset($_SESSION['success_message']); ?>
+        <?php endif; ?>
+        <?php if (isset($_SESSION['error_message'])): ?>
+            <div class="alert alert-danger alert-dismissible fade show" role="alert">
+                <?= htmlspecialchars($_SESSION['error_message']); ?>
+                <button type="button" class="close" data-dismiss="alert" aria-label="Close">
+                    <span aria-hidden="true">&times;</span>
+                </button>
+            </div>
+            <?php unset($_SESSION['error_message']); ?>
+        <?php endif; ?>
+    </div>
+
+    <div class="container form-container">
+        <div class="text-center mb-4">
+            <h1 class="section-title">Program Change Request / プログラム作成・変更依頼書</h1>
+        </div>
+
+        <form action="submit_request.php" method="POST">
+            <!-- Requester Info -->
+            <div class="form-section">
+                <div class="row mb-3">
+                    <div class="col-md-6">
+                        <label for="requestDate" class="form-label">Request Date / 依頼日</label>
+                        <input type="date" class="form-control" id="requestDate" name="request_date" value="<?= date('Y-m-d'); ?>">
+                    </div>
+                    <div class="col-md-6">
+                        <label for="relatedRequestNo" class="form-label">Related Change Request No. / 関連依頼No.</label>
+                        <input type="text" class="form-control" id="relatedRequestNo" name="related_request_no">
+                    </div>
+                </div>
+                <div class="row mb-3">
+                    <div class="col-md-4">
+                        <label for="requesterDept" class="form-label">Department / 所属</label>
+                        <select class="form-control" id="requesterDept" name="requester_dept">
+                            <option value="" disabled selected>Select Department</option>
+                            <option value="RSS JP Sales" <?= ($department == "RSS JP Sales") ? "selected" : "" ?>>RSS JP Sales</option>
+                            <option value="RSS EA Sales" <?= ($department == "RSS EA Sales") ? "selected" : "" ?>>RSS EA Sales</option>
+                            <option value="RSI Sales" <?= ($department == "RSI Sales") ? "selected" : "" ?>>RSI Sales</option>
+                            <option value="RSM Sales" <?= ($department == "RSM Sales") ? "selected" : "" ?>>RSM Sales</option>
+                            <option value="RSP Sales" <?= ($department == "RSP Sales") ? "selected" : "" ?>>RSP Sales</option>
+                            <option value="RSS ACC" <?= ($department == "RSS ACC") ? "selected" : "" ?>>RSS ACC</option>
+                            <option value="RSS HRADM" <?= ($department == "RSS HRADM") ? "selected" : "" ?>>RSS HRADM</option>
+                            <option value="RSS WH" <?= ($department == "RSS WH") ? "selected" : "" ?>>RSS WH</option>
+                            <option value="RSS SA" <?= ($department == "RSS SA") ? "selected" : "" ?>>RSS SA</option>
+                            <option value="RSS IS" <?= ($department == "RSS IS") ? "selected" : "" ?>>RSS IS</option>
+                            <option value="RSS QA" <?= ($department == "RSS QA") ? "selected" : "" ?>>RSS QA</option>
+                        </select>
+                    </div>
+                    <div class="col-md-4">
+                        <label for="requesterName" class="form-label">Requester Name / 依頼者氏名</label>
+                        <input type="text" class="form-control" id="requesterName" name="requester_name" value="<?= htmlspecialchars($full_name); ?>">
+                    </div>
+                    <div class="col-md-4">
+                        <label for="requesterTel" class="form-label">TEL</label>
+                        <input type="text" class="form-control" id="requesterTel" name="requester_ext">
+                    </div>
+                </div>
+            </div>
+
+            <!-- Change Details -->
+            <div class="form-section">
+                <h2 class="section-title">Change Details / 変更内容</h2>
+                <div class="row mb-3">
+                    <div class="col-md-6">
+                        <label for="systemName" class="form-label">System Name / システム名</label>
+                        <input type="text" class="form-control" id="systemName" name="system_name">
+                    </div>
+                    <div class="col-md-6">
+                        <label for="programName" class="form-label">Program Name / プログラム名</label>
+                        <input type="text" class="form-control" id="programName" name="program_name">
+                    </div>
+                </div>
+                <div class="row mb-3">
+                    <div class="col-md-12">
+                        <label for="changeTitle" class="form-label">Change Title / 変更の件名</label>
+                        <input type="text" class="form-control" id="changeTitle" name="change_title">
+                    </div>
+                </div>
+                <div class="mb-3">
+                    <label class="form-label">Change Category / 作成・変更区分</label>
+                    <div>
+                        <div class="form-check form-check-inline">
+                            <input class="form-check-input" type="radio" name="change_category" id="newProgram" value="New" checked>
+                            <label class="form-check-label" for="newProgram">New / 新規</label>
+                        </div>
+                        <div class="form-check form-check-inline">
+                            <input class="form-check-input" type="radio" name="change_category" id="modifyProgram" value="Modification">
+                            <label class="form-check-label" for="modifyProgram">Modification / 変更</label>
+                        </div>
+                         <div class="form-check form-check-inline">
+                            <input class="form-check-input" type="radio" name="change_category" id="bugFix" value="Bug Fix">
+                            <label class="form-check-label" for="bugFix">Bug Fix / 不具合</label>
+                        </div>
+                    </div>
+                </div>
+                <div class="mb-3">
+                    <label for="reasonForChange" class="form-label">Reason for Change / 理由</label>
+                    <textarea class="form-control" id="reasonForChange" name="reason_for_change" rows="4"></textarea>
+                </div>
+                <div class="mb-3">
+                    <label for="descriptionOfChange" class="form-label">Description of Change / 内容</label>
+                    <textarea class="form-control" id="descriptionOfChange" name="description_of_change" rows="6"></textarea>
+                </div>
+            </div>
+
+            <div class="text-center">
+                <button type="submit" name="submit_action" value="Submit" class="btn btn-primary">Submit / 提出</button>
+                <button type="submit" name="submit_action" value="Draft" class="btn btn-secondary">Save as Draft / 下書き保存</button>
+            </div>
+        </form>
+    </div>
+
+    <script src="https://code.jquery.com/jquery-3.5.1.slim.min.js"></script>
+    <script src="https://cdn.jsdelivr.net/npm/@popperjs/core@2.5.2/dist/umd/popper.min.js"></script>
+    <script src="https://stackpath.bootstrapcdn.com/bootstrap/4.5.2/js/bootstrap.min.js"></script>
+</body>
+</html>
\ No newline at end of file
