Application Form for Disclosure, etc. of Retained Personal Information
DATE (m/d/y)：
To: HPD Corporation
In accordance with the provisions of the Act on the Protection of Personal Information, those who wish
to request disclosure, notification of purpose of use, correction, addition, partial deletion, suspension ofuse, total deletion, disclosure of records of provision to third parties or suspension of provision to third
parties of their personal information should complete the required information below and send it alongwith identification documents by registered or specific recorded mail to the Contact Desk below. If awritten response is required from us, we will send it back by ID confirmation delivery service at theexpense of the requestor. Please contact us in advance to enclose postal stamps equivalent to the actual
cost when sending the application documents.

Name ofthe Person
Concerned
Address

Date of Birth〒(m/ d/ y )(m/ d/ y )-TelephoneHome
Mobile Phone・Work Phone
If the request is made by a proxy, please fill out below as well.
Name ofProxy

Date of BirthAddress of〒Proxy
Telephone ofHomeProxy
Mobile Phone・Work PhonePosition of□Legal Representative □Arbitrary Proxy □Other（）
ProxyRelationship□Parental Authority □Adult Guardian □Successor □Other（）with the PersonConcernedYour Contact from Us① Phone ：－－（□Mobile □Home □Work）②E-mail ：Destination of Reply□Postal Mail to the Person concerned□Postal Mail to the Proxy□E-mail to the Person concerned□E-mail to the Proxy
Request（Please write a check mark in the appropriate field and provide specific details and reasons.）□Disclosure □Notification of Purpose of Use □Correction □Addition□Partial Deletion□Suspension of Use □Total Deletion□Disclosure of records of provision to third parties □Suspension of provision to third parties
Request Details

ReasonIdentification documents of the person concerned（Please write a check mark on the enclosed documents.）
A：Copy of one of the following (within expiration date)□Driver's License□Passport□Individual Number Card (Front side only)□Disability Certificate□Residence Card
□Special Permanent Resident Certificate
B：Any two of the following, if you do not have the documents listed in A above□Copy of Health Insurance Card (within expiration date)□Copy of Pension Book (within expiration date)□Transcript or Extract of Family Register (within 30 days of issue /original only)□Certificate of Residence (within 30 days of issue /original only)□Certificate of Seal Registration (within 30 days of issue/original only)
Identification documents of the proxy（Please write a check mark on the enclosed documents.）□A or B above for both the person concerned and the proxy
ID of the person concerned（） ID of the proxy（）（In the case of a request by a “legal representative”）□Documents to prove the qualification of the legal representative (e.g. Transcript or Extract of Family
Register/within 30 days of issue)（In the case of a request by an “arbitrary proxy”）□Letter of ProxyContact Desk
To: Accounting（Mailing address）
H.P.D. Corporation
Renaissance Okinawa Resort3425-2, Yamada, Onna-son, Okinawa, Japan, 〒904-0416※For inquiry TEL:098-965-0707 Email: privacy@hpd-c.co.jp
Our Entry Field
Date (Receipt)
Date (Processed)
RecipientSupervisor※Personal information provided in connection with this matter will be handled only to the extent necessary
to respond to this request.
※In the event that there is no retained personal information to be disclosed as a result of the investigation,or if the request cannot be processed due to incomplete documentation, etc., a response will be made tothat effect in principle, but please note that the fee will not be refunded.
※Documents submitted will be disposed by appropriate means without delay after the request has beenprocessed.