ANA Crowne Plaza Fukuoka “Request for Disclosure of Personal Information” Form
Date of Request : Day/Month/Year

Disclosure of Personal Information

Please ﬁll out the sections below to disclose the personal information.

□ Room / restaurant reservations (name, details of the reservations <room, restaurants, events>, dates)

Please ﬁll out and submit the identiﬁcation document to the address below.
(It is the applicants' responsibility to pay postage.)
Please ﬁll out the information in bold print.

Please ﬁll out all the sections below.

1. Name reservation was made under

Address for the Request

2.The purpose of the visit to ANA Crowne Plaza Fukuoka (rooms, restaurants, events)：

3. Date of visit to ANA Crowne Plaza Fukuoka

ATT: Privacy Policy ANA Crowne Plaza Fukuoka
3-3-3 Hakataekimae, Hakata-Ku, Fukuoka-shi,
Fukuoka 812-0011, JAPANDay/Month/Year□ Others

We only accept requests by mail. We do not accept requests at the front desk or restaurants.

Personal Information(Please ﬁll out all of the information requested.)
Date of Bir th

Name

Day

/Month/Year

Address

We check reservations and event schedules for free.
*Please write the phone number that we can reach in thedaytime. We might call the number to verify the information.

Phone Number
Identiﬁcation

1. Driverʼs license 2. Passport, 3. Health insurance card 4.Basic resident register card (with a photo) 5. Pension
handbook 6. Physical disability certiﬁcate 7. Alien registration certiﬁcate 8. Proof of personal seal registration.
*Please submit copies of two identiﬁcation documents along with requested documents in an envelop.

ANA Crowne Plaza Fukuoka
In-House System for DisclosureThis form will only be used to disclose the personal・The information provided was inadequate.

discarded after that period of time.

・The information requested to disclose doesn't fall under the "personal data"

information. All documents will be kept for a month andApplicantʼs Information

・The hotel cannot conﬁrm the checklist.
category.

・The disclosure will trouble our business.
・The disclosure is a violation of the law.

(Please ﬁll out the sections below ONLY if the applicant is applying on behalf of someone else.)

・The disclosure of personal information leaves a negative impact on thecustomer. This includes a physical, ﬁnancial or basic welfare detriment.

Name

Address
Phone Number
Relationship
Proof ofidentiﬁcation
and relationshipApplicantidentiﬁcation

Handling

We will notify you with the reason(s) if we decide NOT
to disclose the personal information.

Fee*In case we need to contact you to verify any information,please list a daytime phone number.

1. Relative 2. Legal Guardian
3. Representative 4. Other ; please write the relationship in the parenthesis ()“letter of attorney” which proofs that the applicant is the representative and1. Koseki certiﬁcate (Japanese family registry) or 2. Certiﬁcate of Legal Guardian
1. Driverʼs license 2. Passport, 3. Health insurance card 4.Basic resident register card (with a photo) 5. Pension
handbook 6. Physical disability certiﬁcate 7. Alien registration certiﬁcate 8. Proof of personal seal registration.
*Please submit copies of two identiﬁcation documents along with other documents in an envelop.

■Oﬃcial Use Only

Please include 500JPY postage issued by Japan Post in an envelope.

Manager use only

Date and time of the request