Application date: YearMonthDate

To: Toshiba Automation Systems Service
Personal data Protection Group

Request Form for Personal Data Correction etc.
I hereby make the following request concerning personal information held by Toshiba Automation
Systems Service in accordance with the Act on the Protection of Personal Information.
1. Matters Concerning the person to whom the personal data refers
Information

Affix seal here

Nameconcerning
Postal address

Postal code

personal

Telephone number(data refers

E-mail address

the person－to whomthe－)(Telephone for daytime contact)

Details of the request (Please circle the1. Correction of personal data

2. Addition of personal dataapplicable number.)

3. Deletion of personal data

4. Cessation of use of personal data

5. Cessation of provision of personal data to third parties
Please indicate the specific reason for your request. (Errors in personal data or use forother than the stated purpose without consent, etc.)

Personal identity confirmation document

1. Driver’s license

2. Health insurance card 3. Passport(Please circle the document included with

4. Pension booklet

5. Resident registry card

this form.)

6. Duplicate of original alien registration(Please send a copy of the document.)

2. Describe how you provided your personal data to Toshiba Automation Systems Service(Circumstances and means of disclosure)(Please circle the applicable number and specifically indicate the product or service name.)
Inquiry number, name of product, service purchased, etc.

1.

User card2.

E-mail newsletter

3.

Membership subscription form

4.

Questionnaire, campaign

registration form

entry form, productmonitor registration form, etc.
5.

Exhibition registration form
(exhibition name, date, etc.)

6.

Repair request

7.

Inquiry8.

Other3. Describe how you were contacted by Toshiba Automation Systems Service(After indicating the specific product or service name, circle the applicable items.)

Concerning
1. I receive direct mail.
3. I receive telephone calls.
5. Other ((specific product or service name)
2. I receive e-mail.
4. I receive visits.
)

4. Correction of personal data (When requesting correction, please indicate the information to be corrected.)
Personal data item
(name, postal address,telephone number, etc.)

Before correction

After correction

5. Addition of personal data (When requesting addition, please indicate the information to be added.)
Personal data item
(name, postal address,telephone number, etc.)

Personal data to be added

6. Deletion of personal data (When requesting deletion, please indicate the details.)
Specific product or service name, details of use, etc. of the product or service for which personal data is to be deleted

7. Cessation of use of personal data or cessation of provision of personal data to third parties(When requesting cessation of use of personal data or cessation of provision of personal data to third parties, pleaseindicate the details.)
Specific product or service name, details of use, etc. of the product or service subject to cessation of use of personal dataor cessation of provision of personal data to third parties

Note: No fee is necessary for requests for correction, addition, deletion, cessation of use, or cessation ofprovision to third parties. The requestor bears the cost of postage to Toshiba Automation Systems Service.
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Office(Date stamp)

Remarks