Request for disclosure etc. of personal data held
Date (MM/DD/YYYY): 20_____/_____/_____
To: Personal Information Hotline, General Affairs Dept., General Affairs Div.,
Mitsui Fudosan Retail Management Co., Ltd.
Pursuant to the Act on the Protection of Personal Information, I hereby request disclosure etc. of personal data you
hold or records of provision to third parties, as described below.
Details
Person subject to disclosure etc.

Postal code:-Address:
Kana
Name:

(Seal)

Contact tel.: (--)

Identification (Enclose a copy of one of the following documents.)□ Driver's license□ Passport□ Health insurance card (mask out the insured code/no. and similar information)
Fill out the following information if the requester is a legal representative or proxy.
Postal code:-Address:
Kana
Name:

(Seal)

Contact tel.: (--)

Representative

Check the appropriate category of requester:□ Legal representative □ Proxy

Identification (Enclose a copy of one of the following documents.)□ Driver's license□ Health insurance card (mask out the insured code/no. and similar information)
Documentation of eligibility to request disclosure as representative (Enclose one of the following
documents.)<Legal representative><Proxy>□ Copy of family register□ Letter of attorney□ If a parent or guardian, copy of health insurance card showing
dependent family members(mask out the insured code/no. and similar information)

Item(s) requested

No.

(Circle the number[s] of the item[s] requested)

1

Notification of purposes of use of personal data held * 1,500 yen/request

2

Disclosure of personal data held * 1,500 yen/request

3

Correction of, addition to, or partial deletion of content of personal data held
(Enter the content before and after these changes under "Details of correction etc.")

4

Cessation of use of personal data held

5

Full deletion of personal data held

6

Cessation of provision of personal data held to third parties

7

Disclosure of records of provision of personal data held to third parties * 1,500
yen/request

Notification of response

A response will be sent by post to the address you choose for notification of response.
Send notification of response to: □ Address of person subject to disclosure etc.

□ Address ofrepresentative
For demands for items 1, 2, and 7, also choose the requested response format.
Response format: □ In writing □ Electromagnetic records (response will be made after saving therecords to CD-ROM or other media)* In principle, responses through electromagnetic records will be made in PDF format.
Describe the personal information subject to your request in as much detail as possible.

Subject of request

Also provide the following information to the extent known.
･ Facility to which personal information was provided ()Ex.: LaLaport ○○, Mitsui Outlet Park○○･ Situation in which personal information was provided()Ex.: Product purchase, during ○○ promotional campaign, during ○○ survey･ Timing of provision of personal information (around the month of, 20_____)

Be sure to fill out the following information if the personal information subject to the request concerns
MSP membership information. In other cases as well, provide the following information to the extent
MSP membership information

known, for reference in checking on personal data held.
(Correction and withdrawal of membership also can be conducted using the members' page or thecontact telephone number. Contact Credit Saison Co., Ltd. to withdraw from membership for a cardwith a credit feature.)･ 12-digit point no. (--)

･ Date of birth (MM/DD/YYYY) (20_____//)･ Registered telephone no. * Enter your registered telephone no. if it differs from the contacttelephone no.
□(-□ Address<Before><After>Details of correction etc.

□ Telephone no.
<Before><After>□ Email address<Before><After>□ Other<Before><After>-) ･ □ Same as contact telephone no.