Form for various requests
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 various request
ANA Cargo Inc.
Personal Information Handling Desk
1-5-2, Higashi-Shimbashi, Minato-ku, Tokyo, Japan, 105-7140
Please note that this form is accepted only by mail.
Information for Identifying Person to Whom various requests 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 enclosed with this form. Photo ID
is required as one of the documents.
Examples 1. Driver’s license 2. Passport 3. Health insurance card (masking insurance card numbers
and identification symbols / numbers of insured individuals) 4. Basic resident registration card withphoto 5. Pension book 6. Physical disability certificate 7. Resident card or Special permanent
resident certificate 8. Certificate of seal registration 9. Individual Number Card (front page only)

Documents toconfirm identificationof the principal

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

Last Name

Birth DateFirst Name
AddressDay

Month/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（）
document)

Documents to confirm Identification of representative*Please note that copies of two documents from thebelow should be enclosed with this form. Photo ID isrequired as one of the documents.
Examples 1. Driver’s license 2. Passport 3. Healthinsurance card (masking insurance card numbers andidentification symbols / numbers of insured individuals)
4. Basic resident registration card with photo 5. Pension
book 6. Physical disability certificate 7. Resident
card or Special permanent resident certificate 8.
Certificate of seal registration 9. Individual Number
Card (front page only)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．Change
２．Deletion
３．Addition
４．Discontinuance of Usage
５．Erasure
６．Notice of Purpose of Use
７．Withdrawal of Consent
８．Request for Receiving
９．Request for Handover
１０．Objection
１１．Provision of information on personal
information protection measures

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 ANA’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 ANA Cargo Inc.
Management representative validation

Acceptance date and time
Received on : YearMonthDateTime：
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