Form for various requests < for EEA／UK residesnts>
Request Date：//

Please fill out the Form below and return to the Personal Data Information Desk with all documents required forconfirmation of identification. (Postage stamps required.) Please fill out all items below.
Personal Data Information Desk for modification request
OCS America Inc.
22912 Lockness Avenue, Torrance, CA 90501
Attn: HR Department
Please be careful not to forget to fill in the required items in the bold frame.
Note: Use of this form is not mandatory, but please clarify the matters listed in this form when making a request, andsend to the Personal Data Information Desk shown above.

Information for Identifying Person to Whom Modification etc. Pertains（We may not be able to accept disclosure if all columns have not been completed.）

Last Name

Birth DateFirst Name
AddressDay

Month/Year/

Zip Code*As we may call for identification, please fill in daytime phonenumber.
Note: In order to confirm identification, please enclose one of the documents listed below with this form. Please beaware that there may be cases in which the presentation of additional documents may be necessary in order for ourcompany to complete confirmation.

Telephone－Documents to－

1. Driver’s license 2. Passport 3. Health insurance card (masking insurance card numbers andidentification symbols / numbers of insured individuals) 4. Basic resident registration card with photo
5. Pension book 6. Resident card or Special permanent resident certificate 7. Certificate of seal
registration 8. Individual Number Card (front page only)

confirm identificationof the principal

Information on Person Requesting for Modification etc.
(Please fill this out only if the request is being made through a representative.)

Last Name

Birth DateFirst Name
AddressMonth/Year/

Zip CodeTelephone－－*As we may call for identification, please fill in daytime phone
number.

Documents required
Relationship to the individualDocument to verify relationship to the individual

1.A person with parental authority

Person’s family register

2.Guardian of an adult

Guardian certificate
Letter of trust

3.Representative(Legal representatives shall provide certifying（Day）
document)

Types of request to be handled
Circle the number for the type of requests to be handled and fill out details.

Types of Request

Details

１．Disclosure
２．Correction or updating
３．Erasure
４．Restriction of information usage
５．Transferring
６．Objection
７．Withdrawal of consent

Handling of this request form
We will handle the documents we are presented with only to the extent that is necessary, in accordance with our privacy
policy.
Please refer to the following link for our privacy policy.
https://www.ocsworld.com/Privacy.aspx

Denials for disclosure and the reasons will be notified.
Please be informed that, in some cases, we may not be able to disclose the information requested because it does notexist or because the request cannot be met due to laws and regulations. Should such case occur, we will notify you ofthe denial of disclosure and the reasons.

■For official use by OCS
Management representative validation

Acceptance date and time
Received on : YearMonthDateTime：