To: Media Do Co., Ltd. Personal information inquiry desk

Request Form for Disclosure of Personal Information
Date: Year ______ Month ______ Day ______
I request the disclosure, etc. of personal information from MEDIA DO Co., Ltd.
Requestor

・The individual

・Legal representative of a minor(Please circle)

・Legal representative of an adult ward

・Representative authorized by the individual*If you are the individual, please fill in the individual column below, and if you are a representative, please fill inthe representative column below.

The individual

Postal CodeAddress
Furigana (phonetic guides)
Name
Contact telephone

The representative

Postal Code
Address
Furigana (phonetic guides)
Name
Contact telephone

Request items

Item No.

Request Items (Please circle the item number that applies):

1

Notification of the purpose of use of personal information

2

Disclosure of personal information

3

Correction of personal information

4

Addition of personal information

5

Deletion of personal information

6

Suspension of use of personal information

7

Erasure of personal information

8

Suspension of provision of personal information to third parties

Preferred Method（Please check ☑ for your preferred method of response）

of Response□ E-mail (file with PW)□ Mail (750 yen handling fee will be charged)

Handling of Personal Information
I agree to the “Handling of Personal Information in Disclosure” and send the required documents on the “Request Form forDisclosure of Personal Information.”

For the Company Use Only
Verification ofDriver's license

Passport

Copy of resident certificate

individual / representative

Other (Verification ofFamily register (full copy / extract)

Certificate of matters described in residence record

representative's qualification

Power of attorney

Other (Person in charge

Received on: Year ______ Month ______ Day ______of reception

Receiving person: __________________PMR judgment□ Subject to disclosure)□ Not subject to disclosure

Reason for judgment
PMR approval

Approval Date: Year ______ Month ______ Day ______□ Approved as stated above)

Handling of Personal Information in Disclosure【Personal information protection manager】

Personal information protection manager, Executive officer and CIO
TEL: 03-6212-5113

E-mail: privacy@mediado.jp【Purpose of use】

Personal information received at the time of a request will be used only for the purpose of responding to the disclosure, etc.
【Provision to third parties】

We will not provide your personal information to any third party.
【Outsourcing】

We will not outsource the handling of personal information provided at the time of request in order to respond to requests
for disclosure, etc.
【Provision of information】

The provision of personal information to the Company is entirely voluntary.
However, if you do not provide the information we request, we may not be able to properly disclose your information.
【Identity verification】

We will verify your identity by comparing the personal information in our possession with the identification documents yousent us. If the request is made by a representative, the identity of the representative will be verified by the documents sent.
In addition, if the identity of the applicant or his/her representative cannot be verified, the applicant may be asked to submit
verification documents again.
【Return of personal information】

Personal information received for the purpose of identity verification or representative verification will be returned
immediately after the response is made.
【About fees】

If you wish to receive a response regarding notification of purpose of use or disclosure of your personal information by mail,a handling fee of 750 yen (including consumption tax) will be charged for each request. Please enclose a stamp or postal
money order for the fee when you mail your request form to us. (If you send the request form as an e-mail attachment,
please send us only the fee and required documents by mail.)If the fee is insufficient, we will contact you. If the payment is not made within one week after the contact, the request will beconsidered invalid.
【Where to request disclosure, etc.】

Address: 5F, PALACESIDE Bldg., 1-1-1 Hitotsubashi, Chiyoda-ku, Tokyo 100-0003, Japan
TEL: 03-6212-5113
Send To: Personal information protection manager, MEDIA DO Co., Ltd.
E-mail: privacy@mediado.jp*Please do not send specific e-mails.

【Identity verification documents】(1) When making a request, please send us a “Request Form for Disclosure of Personal Information” along with one of thefollowing documents to confirm your identity.
・ A copy of a driver's license, passport, or other photo identification document (showing the name and address of theperson making the request for disclosure, etc.)
・ A copy of the certificate of residence (made within 30 days prior to the date of the request for disclosure, etc.)(2) If a representative is to complete the procedures, in addition to the “Personal information disclosure request form” and(1) above, one of the following documents must also be sent by mail.
・ A document certifying the representative, a copy of the representative's driver's license, passport, or other documentthat can be used to verify the representative's identity with a photograph (showing the name and address of therepresentative making the request for disclosure, etc.)
・ A copy of the representative's certificate of residence (made within 30 days prior to the date of the request fordisclosure, etc.)
・ If the representative is an attorney, a document showing the attorney's registration number
・ A power of attorney indicating representation