Request Form for Persona Data and Third Party Record Disclosure
Please fill out the following form, attach documents confirming your identity or that of agent , and send it toour Inquiry Counter below (please note that you will bear the postage).
LIXIL Corporation Personal Information Inquiry Center
24F Osaki garden tower, 1-1-1, Nishi-shinagawa, Shinagawa-ku, Tokyo, 141-0033, Japan

1. Information of the requester ( you or your representative）
Please fill out your information（Please fill in all fields.）
Furigana

sealName
Date of birth(YYYY/MM/DD)〒-Address-

Phone number-※Please provide the number that we can reach during the day

EmailWhen requester is a representative, please also fill out the following form
(Please fill in all fields.)
Furigana

seal

Name
Date of birth(YYYY/MM/DD)〒-Address
Phone number--※Please provide the number that we can reach during the day

EmailRelationship

1. Parental authority（

2. Guardian of Adult 3. Agent）

4. Others

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２. Documents confirming that the person is the principal or an agent
Please prepare the following documents (without personal number (My Number)).
Please mask the "symbol", "number", "insurer number" and "QR code" on the copy of the health insurancecard. (Example of masking: Use a non-transparent material such as sticky notes or tape to hide the area
before copying. After making a copy, fill the area so that it cannot be seen.)
Case of theA copy of your driver's license, passport, health insurance card, or certificate of residence, etc.
principal

In the case ofan agent① A copy of the person's driver's license, passport, health insurance card, or certificate of residence② A copy of the agent's driver's license, passport, health insurance card, or certificate of residence,etc.
③ Power of attorney indicating representation (If the representative is an attorney, the registration
number and a power of attorney indicating the representative.)④ Certificate of personal seal impression＊ Personal information obtained through this request procedure will be used to the extent necessary for correction
procedures. We will promptly dispose of the documents that you have submitted to us to confirm your identity or
your representative after the correction procedures are completed.
＊ We will not disclose the requested information if the information is incomplete in this form or in the confirmation
documents, or if the requested information does not exist, or if the Act on the Protection of Personal Information
provides that such information may not be disclosed. In such cases, the Company will notify the applicant by mail.

３. Subject of disclosure request
Please tick the subject for which you wish to request disclosure. （※Please specify）□ Personal Data□ Third Party Record

４. How to disclosure
Please tick your preferred method of disclosure. （※Please tick）□ Disclosure by electronic record□ Written disclosure※ Disclosure by electromagnetic record will be made by e-mail. If it is difficult to disclose by electromagnetic record, wemay disclose in writing.
※ If you wish to request disclosure in writing, please write your or your representative's contact information on the addressand enclose a return envelope attached 404 yen stamps (84 yen for regular mail plus 320 yen for registered mail) .

５. Reason for disclosure request（Optional）

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６. History of Provision of Personal DataPlease circle the appropriate number. Please be as specific as possible as to when and where your personal
data was provided, the name of the specific service or campaign, and the name of the product youpurchased.
When and where it was provided, andName of service/product, etc.

History of provision of the service
123456789Owner Registration
Apply for Long-Term
Service
Repair Request⚫

Date of provision (Approximately):

Warranty(YYYY/MM/DD)⚫

Place (XX showroom, XX campaign website, etc.)：⚫

Method of provision (filling out customer card,Purchase Parts and Consumables
Request for brochures and catalogs

registering on website, etc.)：

Visit our showroom
Apply for our campaigns
Contact us by e-mail or phone⚫

Other details：

Others202211