Date/D

To: GMO Pepabo,Inc.

/
MY[Individual]
Address:
Name:
Contact details:[Representative]
Address:

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Name:
Contact details:

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Request Form for Amendment, etc. of Personal Information
I hereby request your company to have the information amended, added, deleted or suspended, or stop provision of theinformation to a third party with respect to the following personal information your company holds concerning theindividual named below, pursuant to the provisions of Article 26, Paragraph 1, and Article 27, Paragraph 1 or Paragraph
2, and Article 29, Paragraph 1 of the Act on the Protection of Personal Information (Act No. 57 of 2003), and Article 17,Paragraph 3, and Article 19, Paragraph 1 of the Guidelines Regarding the Protection of Personal Information in theTelecommunications Business (Ministry of Internal Affairs and Communications Report No. 695, 2004).

1

Personalinformation2

3(Note 1)
(Note 2)

(Note 3)(Note 4)(Note 5)

Actions requested with respect toinformation
 Amendment () Addition()
 Deletion
 Stop usage
 Stop provision to a third party () Amendment ( Addition( Deletion
 Stop usage
 Stop provision to a third party ())

 Amendment ( Addition( Deletion
 Stop usage
 Stop provision to a third party ())))

Reason for requesting the applicable action
 The details are not correct
 The holding period has expired
 The information is being used for a purpose other than theintended purpose () The information is being provided to a third party without one'sconsent
 Other () The details are not correct
 The holding period has expired
 The information is being used for a purpose other than theintended purpose () The information is being provided to a third party without one'sconsent
 Other () The details are not correct
 The holding period has expired
 The information is being used for a purpose other than theintended purpose () The information is being provided to a third party without one'sconsent
 Other ()In the personal information section please specifically indicate such information as “name”, “address”, etc. for which you request amendment, etc.
To prove the individual’s identity please submit to the contact point which handles requests for amendment, etc. of personal information the following forms ofidentification: (1) duplicate of original copy of residence certificate, or (2) duplicate of original copy of matters recorded in the alien registration, and any one of
the following: (3) driver’s license photocopy, (4) passport photocopy, (5) pension insurance handbook photocopy, (6) alien registration card photocopy.
In cases where an application is submitted by a representative, the following shall be submitted: (1) duplicate of original copy of the individual’s residence
certificate, (2) power of attorney, (3) the individual’s original seal certificate used for preparing the power of attorney, and any one of the following: (4)representative's driver’s license photocopy, (5) representative’s passport photocopy, (6) representative’s pension insurance handbook photocopy, or (7)representative’s alien registration card photocopy.
The Company shall only use the personal information obtained in relation to this request for amendment, etc. within the bounds necessary to satisfy the request
for amendment, etc., and will dispose of submitted materials after having kept the materials for a period of six months after responding to said request.
With respect to making a request for amendment, etc. to a business that provides multiple services, please indicate the relevant service when requesting
amendment, etc. of personal information.

[Section for use of business handling personal information]

Request form
received

Confirmation ofrequest details

Response(disclosure/nondisclosure)

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