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[]
[null,null,null,null,null,null,null,null,"年　  　月　  　日"]
[null,"〒105-0001"]
[null,"東京都港区虎ノ門1-16-8"]
[null,"石井ビル3F"]
[null,"MicroWorld株式会社"]
[null,"個人情報問合せ窓口　宛"]
[]
[null,"個人情報開示等請求書"]
[]
[null,"本請求書に記載する個人情報は、貴社が本人確認のみに利用することを同意して、開示対象個人情報の利用目的の通知、開示、訂正・追加又は削除、利用又は提供の拒否の請求をします。"]
[]
[]
[null,"●個人情報を登録（資料請求、申込、契約、取引など）された時の状況をお教えください。"]
[]
[]
[]
[null,"時期",null,"　　　　　　年　　　　　月　　　　日　頃　※お分かりになる範囲で結構です"]
[]
[null,"●開示（利用目的の通知を含む）の場合、そのご請求内容をご記入ください。"]
[]
[]
[]
[]
[null,"●訂正（追加・削除を含む）の場合、必要事項を記入してください。"]
[]
[null,"訂正の\n内容","訂正前",null,null,null,"訂正後"]
[]
[]
[]
[]
[null,"●利用の停止、消去又は第三者への提供の停止の場合、下記より選択してください。"]
[]
[null,"□利用の停止",null,null,"□情報の消去",null,null,"□第三者への提供の停止"]
[null,"理由","（差支えがなければ上記を希望する理由をお書き下さい。）"]
[]
[]
[]
[null,"●請求者情報"]
[]
[null,"ご本人様","ふりがな"]
[null,null,"氏名"]
[null,null,"住所"]
[null,null,"電話番号"]
[]
[null,"代理人様","ふりがな"]
[null,null,"氏名"]
[null,null,"住所"]
[null,null,"本人との関係","□法定代理人",null,"□委任による代理人"]
[null,null,"委任状","□ご本人様自署の委任状および印鑑登録証明書"]
[null,null,null,"□親権者などの法定代理人の場合は、本人との関係がわかる書類（　　　　　　　　　　）"]
[null,null,null,"※上記のうちひとつ"]
[null,null,"本人確認資料","□運転免許証",null,"□住民票の写し",null,"□健康保険証"]
[null,null,null,"※上記のうちひとつ　※コピーは本籍地を塗りつぶしたものをご用意下さい。"]
[]
[null,"●手数料について"]
[null,"500円の郵便定額小為替を本請求書に添えてください。　※利用目的の通知および開示に関わる場合のみ"]

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