Date of issue://( Year / Month / Day )PF-A7-01A-Eng

TO: NEC Networks & System Integration Corporation

Application for Disclosure or Notification of Purpose of Use ofPersonal Information
Information of Principal
Name (mandatory)
Address (mandatory)
Phone number (mandatory)
Type of Request (mandatory)□Disclosure of Personal Information□Notification of Purpose of Use of Personal Information

Subject to Disclosure (mandatory)□Name □Address □Phone number □E-mail address*Mark on Subject for request□Other （）Information of Representative (Only for request entrusted to Representative.)*If age of Principal is 16 or less, an agreement with a person in parental authority is required.
NameAddress
Relationship with Principal□Person in parental authority□Guardian of adult□Other ()Certification to be enclosed (mandatory for Request for Disclosure of Personal Information)*Please mark document to be enclosed

Cat. AOne copy of any of the items below□Driver's license □Passport□Transcript of the family register □Extract of the family register

Request□Health insurance card

Made by□Alien registration card □Residential basic book card

Principal□Face of individual number card * Please do not send the reverse side of the*One of each ofindividual number card in which individual number is recorded.

Items Cat. A and* Please process, by blacking out, the domicile of origin information.

Cat. B is required.

Cat. BOne certified copy of any of the items below□Certified copy of residence certificate□Certified copy of certificate of matters in the alien registration records

One copy of any of the items below

RequestMade byPerson
belonging toCompany orOrganization

One copy of any of the items below of Principal

Cat. A□Transcript of the family register□Extract of the family register

Request□Certificate issued by a family court

Made by□Certificate of registered matters and a document certifying the qualification

Representativeof such person*Case of Request* Must be issued within 30 days before making request

made on parental* Please process, by blacking out, the domicile of origin information.

authority or by

One copy of both items below

Cat. B

Guardian of adult,□Letter of Proxy with the signature and seal of the principal

one of each of Items□Seal certificate for the same seal as the principal’s seal that is affixed on theCat. A, Cat. C andCat. D is required.

letter of proxy
One copy of any of the items below of Representative

Cat. C*Case of Request□Driver's license □Passport

made by□Transcript of the family register □Extract of the family register

Representative□Health insurance card

trusted by principal,□Alien registration card □Residential basic book card

both Items Cat. B□Face of individual number card * Please do not send the reverse side of theand one of each ofindividual number card in which individual number is recorded.

Items Cat. C andCat. D are required.

* Please process, by blacking out, the domicile of origin information.
One certified copy of any of the items below of Representative

Cat. D□Certified copy of residence certificate□Certified copy of certificate of matters in the alien registration records* Personal information we acquired regarding your request to be used only for within the scope necessary for handlingthe case.
* Acquired Personal information is managed by our Personal Information Protection General Service Office.
* About Contact Address for Forwarding of your request, required postage stamp for return and additional charge,
please see our Privacy Policy.
<Company Use> Requester NOT fill in
本人確認書類□運転免許証□パスポート□その他（）

担当部門（事業部等）
対応内容

例外事項対応理由：

承認※請求に従わない例外事項と判断した場合に記入（個人情報保護管理者の承認要）。

対応完了日
備考年月日