Request Form (Form B).pdf

Please check the applicable items.
Furigana
Name
Address
Phone number
( )
Please fill in a phone number that can be reached during the day.
Email address
Relationship with the target person: 1 myself, 2 agent, 3 parent
Please fill in the circle for the applicable item.
Submitted documents
(For the person themselves)
Target person (not required if the person themselves is making the request)
Furigana
Name
Address
Phone number
( )
Please fill in a phone number that can be reached during the day.
Email address
Scope of personal data held
Please specify the name, type, etc. of the personal data held.
(Example) Kabuki club membership registration information, campaign application information, survey response information
Requester (person themselves or agent)
Address
Please submit one of the following:
1 My Number Card (front side only)
2 Driver's license
3 Passport
4 Residence card
5 Disability certificate
6 Health insurance card
7 Pension handbook

Only the front side of the My Number Card will be accepted. If the back side is sent, it will be discarded.
If submitting 1-5, please prepare a copy.
* If submitting 6-7, please attach a copy of the residence certificate.
□ Power of attorney (for agents)
□ Family register (for parents)
Address
Application for request
Request details
□ Correction of personal data held
□ Addition of personal data held
□ Deletion of personal data held
□ Stop providing personal data to third parties
□ Send by mail
□ Send by email
□ Deletion of personal data held
□ Stop using personal data held
Submitted documents
(For agents)
(For parents)
Please refer to the notes in the "person themselves" section.
Correction
Item to be corrected
Before correction
After correction
Addition
Item to be added
Content to be added
Reason for correction
(Example) Handling personal information beyond the necessary scope without consent
Stop providing to third parties
Third party to stop providing to
Deletion
Reason for deletion
(Example) Handling personal information beyond the necessary scope without consent
Stop using
Deletion
Item to be deleted
Content to be deleted