Application for Disclosure of Retained Personal Data
Attn: Customer Relations Office, KOKUYO Co., Ltd.
Date: MM/DD/YYYYItem
1

Entry field

Name of person to be

ExampleIchiro Suzuki

disclosed2

Current address

x-x-x

Otemachi,Chiyoda-ku, Tokyo
3

Telephone number

03-xxx-xxxx

4Company

KOKUYO ●● Co., Ltd.

5

Retained personal data

Request items
Select and describe theinformation that you would
like disclosed from among
retained

personal

data

and records provided tothird parties.
6Context

attimeofprovisionofpersonalinformation⚫
⚫

Date

10am
Sales Division 1

andtimeof

Taro Kokuyo

provision

Enquired via telephone

Department

about

information

wasprovided to⚫

Jan 1, 2005, at around

Namethatnearbycarry

storesKOKUYOstationery products.
ofrepresentative
information

wasprovided to⚫

Method and details ofprovision

7

Personal
provided

informationName,numbertelephone

8

Name of applicant(Also

includecurrent

address if applicant isdifferent

from

Seal

theindividual to be disclosed)
9

Relationship to individualSame person

to be disclosed
10 Methodof
response
Selectandindicate
whether you would like a
response by mail or email.
If you would like a
response by email, indicate
your email address.

MailRemarks:
1. A fee of 1,000 yen is required for each disclosure application. (Please enclose a postage
stamp of the same amount with this application)
2. Please be sure to enclose identity verification documents if the applicant in Item 7. is thesame person as the individual to be disclosed. If the application is a different person,
please be sure to fill in “Item 8. Relationship to individual to be disclosed” and enclose
documents that verify the relationship. In addition, please note that it is not possible forthe disclosure documents to be sent if the address stated in the verification documents
differs from the current address. The required documents are as listed under “Notes”.
3. Only one company and one person can be requested for disclosure with this application.
Even if multiple companies and names are entered, only one company and one person
will be disclosed with this application.

For official use only
Date and time of receipt
Receipt no.

Please read the Notes on the next page.

Notes
1. Items available for disclosure
Retained personal data or records provided to third parties regarding the “targetcompany” and “individual to be disclosed”, such as names, addresses, telephone
numbers and email addresses.
2. Request for disclosure (mailing address)
6-1-1 Oimazato-minami, Higashinari-ku, Osaka-shi 537-8686
Customer Relations Office, KOKUYO Co., Ltd.
3. Items to be submitted for request for disclosure(1) Application for Disclosure of Retained Personal Data
(2) Fee for request for disclosure (1,000 yen postage stamp)
We will inform you in the event that the disclosure fee is insufficient or not enclosed,
but if there is no payment within the prescribed period, we will deem the request fordisclosure invalid.
(3) Documents to verify identity or qualification of agent(i)

If the applicant is the same person

One copy of any of the following: copy of driver’s license or passport (portion
that lists name and current address), certificate of seal impression (originalcopy only), certificate of residence (original copy only), health insurance card.
Certificate of seal impression and certificate of residence will be enclosed
and returned in the reply.
(Note): Please black out your permanent domicile on copies of documentsthat list your permanent domicile.
(ii)

If the applicant is a different person(a) In the case of a legal representative
The prescribed declaration form and documents certifying statutory
power of representation (for example: extract of family register,certificate of residence (including relationships)).
Legal representative verification documents (such as a copy of thedriver’s license of the legal representative, corresponding to identity
verification documents.)(b) In the case of an agent
The prescribed power of attorney and the person’s certificate of seal
impression (within 3 months of creation).

4. Method of replies to requests for disclosure
In response to a demand for disclosure, we shall, in accordance with the wishes of theperson making the demand, provide a written response to the requesting party’saddress specified in the application form or attach an electronic record to an email sent
to the email address specified in the application form (if disclosure using the lattermethod is problematic, we will provide notice to that effect, and respond using theformer method).
5. Purpose of use of personal information acquired through requests for disclosure

Personal information acquired through requests for disclosure shall only be handledwithin the scope necessary for disclosure. Documents submitted will be stored for
two years after the answer to the request for disclosure is completed and will bediscarded thereafter.
6. Reasons for non-disclosure of retained personal data or records provided to third parties
We will not disclose retained personal data in the following cases. We will notify
applicants regarding the reasons should we decide on non-disclosure. In addition, wewill still be charging the prescribed fee even in cases of non-disclosure.
(i)

In cases where the identity of the person cannot be confirmed, such as if theaddress stated in the application is different from the address stated in theidentity or agent qualification verification documents.

(ii)

In cases where the authority of representation of the agent applying cannot beverified.

(iii)

In cases where the prescribed application form is not completed.

(iv)In cases where the subject matters of the demand for disclosure does notconstitute retained personal data(v)

In cases where there are risks of serious hindrance to the proper implementationof our business activities.

(vi)

In cases where it is stipulated by other laws and regulations or in cases wheredisclosure violates other laws and regulations.