Form requesting disclosure <For Residents in China>
Request Date：//

Please fill out the Form below and return to the Personal Data Information Desk with all documents required for
confirmation 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.
Information for Identifying Person to Whom Disclosure Pertains（We may not be able to accept disclosure if all columns have not been completed.）

Last Name

Birth DateFirst Name
AddressDayMonth/Year/

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

*Please note that copies of two documents from the below should be attached with this form. Photo ID
is required as one of the documents.
Examples 1. Passport 2. Health insurance card (masking insurance card numbers and identification
symbols / numbers of insured individuals) 3. Basic resident registration card with photo 4. Pension
book 5. Physical disability certificate 6. Resident card or Special permanent resident certificate 7.
Certificate of seal registration 8. Individual Number Card (front page only) 9. identification card issued
by the Chinese government

Documents toconfirm identificationof the principal

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

Last Name

Birth DateFirst Name
Address

DayMonth/Year/

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

Documents requiredRelationship 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（）
document)

Documents to confirm Identification of representative*Please note that copies of two documents from thebelow should be attached with this form. Photo ID isrequired as one of the documents.
Examples 1. Passport
2. Health insurance card
(masking insurance card numbers and identification
symbols / numbers of insured individuals) 3. Basic
resident registration card with photo 4. Pension book
5. Physical disability certificate 6. Resident card orSpecial permanent resident certificate 7. Certificate ofseal registration 8. Individual Number Card (frontpage only) 9. identification card issued by the Chinese
government

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．Change
３．Deletion
４．Addition
５．Discontinuance of Usage
６．Erasure
７．Notice of Purpose of Use
８．Withdrawal of Consent
９．Request for Receiving
１０．Request for Handover
１１．Objection

Handling of this request form
The personal data obtained in this form is only taken for this request. We will dispose of this form and other related
documents one month after our reply by an appropriate method.

Denials for requests will be notified.
･Required item is missing.
･Confirmation if not available.
･Requested item was not eligible for modification of personal data.
･Request has serious impact to OCS’s business operation.
･Request offends other laws.
･Life, health, property and other rights of the individual or third parties are affected.

■For official use by OCS
Management representative validation

Acceptance date and time
Received on : YearMonthDateTime：