Request Form for Disclosure, Etc.
To: Personal Information Protection Consultation Desk ofDate of preparation: ______________________

Nippon Sanso Holdings Corporation(month) (day) (year)

I hereby request disclosure, etc. of retained personal information as follows.
Content of request(Check-markappropriate item)

Requester( ) Notice of purpose of use( ) Disclosure ( ) Correction( ) Suspension of use( ) Erasure( ) Addition ( ) Deletion( ) Suspension of provision to third parties( ) Disclosure of records of third party provision of personal data( ) Data subject( ) Agent(Check-mark appropriate item)

In katakana characters

Name
Matters concerning(printed)

the data subjectAddress(Complete even if
request is made by anagent)(with postal code)
Birthdate(month) (day) (year)

Telephone No.
Email address
Identity
confirmation
document(Check-markappropriate item)(An identity
confirmation document
is required even if
request is made by anagent)( ) Copy of driver’s license( ) Copy of passport( ) Copy of My Number card (front side only)( ) Copy of residence card( ) Copy of health insurance card( ) Copy of alien registration certificate( ) Copy of special permanent resident certificate( ) Resident record (issued within the past three( ) Copy of physical disability certificate( ) Transcript or abridged version of family register (issuedmonths)

within the past three months)

In katakana characters

Name(printed)
Matters concerning

Address

the agent(with postal code)
Birthdate(month) (day) (year)

Telephone No.
Email address
Identity
confirmation
document for theagent(Check-markappropriate item)( ) Copy of driver’s license( ) Copy of passport( ) Copy of My Number card (front side only)( ) Copy of residence card( ) Copy of health insurance card( ) Copy of alien registration certificate( ) Copy of special permanent resident certificate( ) Copy of physical disability certificate( ) Resident record (issued within the past three( ) Transcript or abridged version of family register (issuedmonths)

within the past three months)( ) Person entrusted by the data subject
Relationship with thedata subject( ) Legal representative (e.g. person who has parental authority or is guardian of adult)(Check-mark appropriate item)

Document
confirming( ) Power of attorney (together with a seal registration certificate of the seal affixed to the power of attorney)authority of( ) Transcript or abridged version of family register (issued within the past three months)

representation( ) Registration certificate of guardian of adult(Check-markappropriate item)

Matters concerning
request(Be as specific aspossible. In the case of acorrection, addition, ordeletion,
write
thecontent of the personalinformation before andafter the correction, etc.)

Name of section to which personal
information was provided
Personal( ) Nameinformation( ) Email address( ) Address( ) Birthdate( ) Others (( ) Telephone No.
)

Reason forrequest* Please use a ballpoint pen.
* The personal information provided in the Request Form for Disclosure, Etc. and the identity confirmation documents will be used to theextent necessary for carrying out the disclosure, etc.
* Enclose postage stamps or a postal money order equivalent to 1,000 yen (including consumption tax) as the fee for each request.