MM DD, YYYY

Request for Disclosure, etc. of Personal Information
To: Tokyo Metro Co., Ltd.
Address:
Name (print name):
Signature:
Pursuant to the provisions of the Act on the Protection of Personal Information (Act No. 57 of 2003), I hereby
request disclosure, etc. of the following “retained personal data” in the possession of Tokyo Metro Co., Ltd.
1.

Nature of request for disclosure, etc. (please check the applicable box)
□Notification of intended use□Disclosure□Correction, etc. (correction, addition and/or deletion)□Suspension of use, etc. (suspension of use or erasure)□Suspension of provision to third parties

2.

□Disclosure of record of provision to third parties

Please specify the details of the nature of the request selected in the above 1.

Note: If you request disclosure, etc. of retained personal data regarding a commuter pass, please provide the following informationin order to identify the retained personal data covered by the request:- When was the commuter pass purchased? ()- Telephone number registered when the commuter pass was purchased: (- Date of birth registered when the commuter pass was purchased: ())- Zone covered by the pass (departure, transit and arrival stations)(Departure station:

Transit station:

Arrival station:)- Type of commuter pass (magnetic or PASMO) (Magnetic pass / PASMO pass)
Note: Retained personal data regarding commuter passes, the disclosure, etc. of which can be requested from Tokyo Metro, islimited to data regarding computer passes issued by Tokyo Metro. Before you request disclosure, etc. of retained
personal data regarding a commuter pass, please check the issuing company of the pass.

3.

If you request a correction, please specify the details of the correction below.
Incorrect (current data)

Correct

4.

Please draw a circle in the box next to the document for identification, of which a copy is enclosed.

If the address, last name, or others are different from those registered in the retained personal data due to the changeof residence, last name, etc., your identity cannot be verified. Therefore, we ask you to take the procedure forcorrections, etc. while making this request. In this case, please enclose a copy of a document providing a proof ofthe change of residence, last name, etc.
Driver’s license
Passport
Health insurance certificate of any kind (medical history is unnecessary)
Basic resident registration card
Abstract of family register (with only necessary particulars such as a name, address etc.)
Residence certificate (with only necessary particulars such as a name, address etc.)
Pension book
In order to identify the relevant “retained personal data” etc. or to handle your request for disclosure, etc., we may
ask you questions or otherwise contact you with respect to the information provided in this request form.
Please choose how you wish to be contacted and please provide your contact details below.
Please check the box next to your choice of means of communication.
□ Mail□ Telephone – Please provide your telephone number:□ Home ()□ Work ()□ Mobile ()□ Email – Please provide your email address: ()We will not use your personal information provided in this request form for any purpose other than for handlingyour request for disclosure, etc.
Unless otherwise specified, your request for disclosure, etc. will be responded to in writing by registered mailaddressed to your address provided in this request form. (If specified, it will be responded in the way you prefer.
However, please understand we may not be able to meet your request.)* Please specify how you wish your request for disclosure etc. to be responded to.
□ Mail (registered mail)□ Email – Please provide your email address: (□ Others* In case you choose “Others” above, please specify details here.

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