Request for the Disclosure of Personal Information Form
Date

To: Help Desk For Requests, Etc. Related to Personal Information
Nippon Electric Glass Co., Ltd.
Pursuant to the Act on the Protection of Personal Information, I hereby submit this request, etc. regarding as follows
the Personal Data the Business Holds concerning the Identifiable Person (me) stated below. (Please enter theinformation required in the form and circle the applicable numbers.)A.

Matters regarding the Identifiable Person (me)Name(seal)

Gender

1. Male2. Female(Please enter the address accurately from the prefecture name, including the zip code.)
Address〒Date of BirthTel.

Documents to

1. Copy of “MyNumber” card

2. Copy of certificate of residence

verify the3. Copy of driver’s license

4. Copy of health insurance ID card

Identifiable

5. Copy of passport

Person*To verify your identity, please fill out the section below if your information registered with the Company isdifferent from the options stated above.
Item(Address,Registered informationetc.)

B.

Matters for the legal representative(Please fill out this section only if the legal representative of the Identifiable Person is submitting therequest or complaint.)

Name(seal)

Gender

1. Male2. Female(Please enter the address accurately from the prefecture name, including the zip code.)
Address〒

Date of BirthDocuments toTel.
1. Copy of “MyNumber” card

2. Copy of certificate of residence1.

verify the legal

3. Copy of driver’s license

representative

5. Copy of passport

4. Copy of health insurance ID card

* Please enclose the power of attorney with the seal registration certification for the seal of the Identifiable Person(who is stated in A. above) affixed thereto.
C.

Matters regarding the Personal Data the Business Holds that is subject to your request, etc.
(Please be as detailed as possible.)* For example, the name of the department of the Company that handled your transaction or with which you havea relationship, the details of such transaction or relationship, the name of the product you purchased, and the like.
D.

Details of your request, etc.
(Please enter the details of your request, etc., the items of Personal Data subject to your request, etc., orthe reason for your request, etc.)

1.

DisclosurePersonalof

Data

Items to be disclosed (Address, etc.)

thetheBusiness Holds
Items to be corrected2.

Correction

toBefore correction

After correction

Before addition

After addition

thePersonal Data

Reason forcorrection
Items to be added3.

Addition

tothe

Personal Data

Reason for
addition

4. Deletion of the Personal

Items to be deleted

Reason for deletion

Items to be suspended

Reason for suspension

Items to be erased

Reason for erasure

Data
5. Suspension of use of
the Personal Data
6. Erasure of the Personal
Data
7. Disclosure of Record ofProvision to third parties[Notes]2.
1. We will respond to your request to the extent of the information entered by you.
2. We will use the Personal Information entered by you to the extent necessary to respond to your request.
3. Information such as the address to send this form to, the documents necessary to verify the Identifiable Person or legal representative thereof, andthe fees can be found on our website.

Name of the third parties to which the provision shall be suspended
8.

Suspension

ofprovision to third parties

Reason for suspension ofprovision to the third parties9.

Provisionofinformation on matters□ I request this provision of information.

regarding the measures(Please tick the box above if you request the provision of information.)takenforthesecurecontrol of the Personal
Data
10. Notification of thepurpose of use* Please enclose one 839 yen stamp per each request for 1., 7., and 10. above for the processing fee.
E.

Other (if any)

Processing result (internal use only)[Notes]2.
1. We will respond to your request to the extent of the information entered by you.
2. We will use the Personal Information entered by you to the extent necessary to respond to your request.
3. Information such as the address to send this form to, the documents necessary to verify the Identifiable Person or legal representative thereof, andthe fees can be found on our website.