Personal Information Disclosure Request Form
Request Date:YYMMDD

TO: Hotel Nikko Osaka■ Postage of request forms and fees

Pursuant to the provisions of the Act on the Protection of Personal Information, I hereby request that you disclose
personal information retained by your company in relation to the following covered person.
(Input required for all items marked ※)Kana
1. Covered Person※
reading

KanaHome
address

SEAL(1) This Personal Information Disclosure Request Form (fully completed with name and seal)(2) Postal note ( kokawase ) for 300JPY(3) Identification documents (still valid and not expired)※※□ Legal Agent□ Discretionary Agent Telephone 1 ※□ Other(If agent request, complete the Telephone 2agent details below.)◇ Please submit a copy of at least one of the following documents (including portrait photo)If the address has changed, attach a copy of the reverse side (showing the change) after the change has been properly registered.

HomeMobile or work

① driver's license, ② passport ③ individual number card (individual number card, including portrait photo side),④ basic residence register card with portrait photo, ⑤ residence card or special permanent resident certificate (showing current address)

Contact forcommunicatio ※ns from hotel◇ If the above documents cannot be provided, at least two of the following documents will be required:① a copy of health insurance card, ② copy of pension book, ③ copy or abstract of family register, ④ residence certificate※ Documents ③ and ④ must have been issued within the last three months.

FAX No.
E-mail

２．Information about Agent, etc.
Relationship to covered□ Parentperson

2. If request is submitted by an agent□ Guardian□ Heir□ Other（）

KanaFull NameSEALTelephone
3. Scope of the disclosure request【Forms required and fees】
1. If request is from the covered person themselves□ Covered Person Full Name ※□ Agent

When making a request, be sure to include the necessary documents listed below and a postal note for 300JPY, and send bysimple registered mail (kani kakitome ) or certified mail ( tokutei kiroku yubin ). Please also write "Disclosure Request Enclosed" on the envelope.

（Circle one : Home ・ Work ・ Mobile）※ (Please give details regarding the personal information requested.)

If the request is submitted by an agent, the following documents are required, in addition to those in 1.(1) through (3) above.
(4) identification documents of the agent (refer to above requirements for covered person)(5) power of attorney, etc.
① If the agent is a person who has parental authority over the covered person: copy of family register of agent (issued within the last three months)② If the agent is the covered person's guardian: the certificate of registered information③ If discretionary agent: a power of attorney (with covered person's registered seal) and seal registration certificate for the seal used(must have been issued within the last three months)■ About the response
A response will be sent in writing by simple registered mail to the address listed on the covered person's identification document.
In the case of a disclosure request by a legal agent, responses are made to the legal agent at the time of the request.

4. Details of Request ※ (Please provide detailed information.)

Responses are also generally made in writing if upon investigation it is found that there is no retained personal data to disclose, or disclosure
cannot be made due to incorrectly completed request form or insufficient documentation. Please note that the fee is non-refundable.
Responses take around two weeks from receiving a disclosure request. Please note, however, that in some cases more time can be required forinvestigation and response.

(COMPANY SECTION) Record Number 【NO.
－】 Note:■Date of request:／／：（AM ・PM) ■ Requested by Phone / E-mail / Other （■ Official identification documents (copy) : 【Identity document No.
】□driver's license □ passport □ individual number card □ basic resident registration card
1 of
□ resident card or special permanent resident certificate□ health insurance card □ pension book □ copy of family register □abstract of family register
2 of□ residence certificate
Person in■ Document evidencing agency right 【】Seal■ Received by :Section Seal /Division
Charge■Response date: ／／Manager
Seal
Manager Seal
■ Chief Privacy Officer : Signature

Seal※ Personal information obtained in the process of a disclosure request is used by the company to carry out this request, confirm the covered person or agent,
for fee handling and to respond to the disclosure request.
）※Personal information documents submitted will be destroyed appropriately without delay upon completing a response to a disclosure request.
Please note that such documents will not be returned.

■ Address for questions or other requests regarding your disclosure request
Hotel Nikko Osaka
Marketing Group
1-3-3,Nishi-Shinsaibashi,Chuo-ku,Osaka,542-0086, Japan
TEL:+81-6-6244-0747(Mon.-Fri. 10:00am-5:00pm<excluding National holidays and New Year>)