Date of Request:
To: SCREEN PE Solutions Co., Ltd.

Personal Information Disclosure, etc. Request Form
Upon approval of the matters described in “3. Provisions Regarding the Procedures for a "Request forDisclosure, etc."” of your Privacy Policy, I hereby request Disclosure, etc. of retained personal data set
forth in the Act on the Protection of Personal Information of Japan as follows.
1. Information regarding the Applicant
Full Name
Date of birthAddress

Phone number〒－()

E-mail addressCompany/Department－※Please enter your complete address※daytime phone number

Nature of yourrequest

1. Notification of purpose of use 2. Disclosure of personal information 3. Revision ofpersonal information 4. Addition of personal information 5. Deletion of personalinformation 6. Suspension of use of personal information 7. Removal of personal
information 8. Suspension of provision of personal information to third parties
9. Disclosure of the record of provision to third parties
In case of 2. Disclosure of personal information or 9. Disclosure of the record ofprovision to third parties, please designate the way of disclosure.
1. letter 2. E-mailReason of yourrequest※Please describe the reason specifically. In the case of No. 6 through No. 8 above, please specify
the name or details of the service.

Situations or methodsof providing personal
information toSCREEN※Please specify the details, such as registration of web service, user, membership, questionnaire,
campaign or exhibition visitor, etc., repair request, license acquisition, application or inquiry.

Identification
document

1. Driver’s License
5. Residence Card
7. Other（※Please circle theappropriate number※Please circle theappropriate number

2. Passport 3. Health Insurance Card 4. Pension Booklet
6. Individual Number Card (front side only)）※One copy of any documents above

12.

Information regarding the Representative ※The following items should be filled out only when

this request is made by a Representative:
Full nameDate of birthAddress〒－Phone number
E-mail address
Identification
document※Please circle theappropriate number(
1. Driver’s License
5. Residence Card
7. Other（)－※Please enter your complete address※daytime phone number

2. Passport 3. Health Insurance Card 4. Pension Booklet
6. Individual Number Card (front side only)） ※One copy of any documents aboveRelationship withthe Applicant

1. Person designated by the Applicant 2. Legal representative (person with parentalauthority, etc.)

Documents
verifying theauthority ofRepresentative

1. Proxy from the Applicant and a certificate of the registered seal affixed to the Proxy(within 3 months from the date of issue)※Please circle theappropriate number※Please circle theappropriate number

3.

or

2. Transcript or abstract of family register, or a copy of residence certificate that shows arelationship with the Applicant（※Only in the case of legal representative）

Other（Comments）<Note>The Applicant must fill in the necessary information in this request form and send it to the “PersonalInformation” Inquiries Office along with the necessary documents. In case of disclosure by letter, pleaseattach postage fee for a response letter (postage stamps equivalent to the postage fee of standard size
domestic mail up to 25 g and Restricted Delivery Mail Service provided by JAPAN POST Co., Ltd.).

2