(Year)__________ (Month)______ (Day)______ NTT DOCOMO, INC.

Letter of Consent I, as legal representative of the subscriber (and as the representative guardian if the subscriber is a minor and more than one guardian exists), give my prior consent to the applicant applying for and entering into a contract based on the contract stipulations, terms of use, etc., and making any other requests (changing the billing plan, etc.) related to the service after it commences. Further, I allow DOCOMO to make and save a copy of my identification document presented for this application. ●Requested procedure, etc. (This section is to be completed by the legal representative.)

Requested Procedure (Circle “1” or “2” on the right. If both 1 and 2 are applicable, please circle both.)

1. New Mobile Phone

Subscription

<Be sure to indicate how many lines the application is for.> 1. Single line (mobile phone) 2. Single line and 2in1 3. Multiple: ( ) lines

2. Other

(application for

model change,

docomo Hikari, etc.)

Requested Procedure*1

Applicable phone number*2 0 0 － －

Mobile Phone Purchase Method*3 (Circle an option on the right.)

12 payments* / 24 payments* / One-time payment □ Utilize Basic Purchase Support*5

*Installment payments for product costing more than ¥100,000 (incl. tax) □Use □Do not use*4

*If using DOCOMO’s installment payment option, your personal credit information will be registered with Member Credit Information Agencies designated by the Ministry of Economy, Trade and Industry based on the stipulations of the Installment Sales Act. Please note that if the subscriber is a minor and a late payment is made by the guardian registered as the payer, the late payment will be regarded as that of the subscribing minor. If information on late payments is registered, applications for credit, loans, etc. may be denied.

Application for Access Restriction Service (filtering service)*6 (Select an option on the right if you will use i-mode, sp-mode, or BlackBerry Internet Service.)

sp-mode

If applying for Access Restriction Customizer or sp-mode Filter Customizer, set a Limit password. Limit password*7

i-mode □ Kids’ i-mode Filter □ i-mode Filter □ Kids’ i-mode Filter + Time Restriction □ Web Restriction □ i-mode Filter + Time Restriction □ Time Restriction only □ Access Restriction Customizer

BlackBerry □ BlackBerry Web Filter

□ Do not apply*8 *If the user is under 18 years of age and Access Restriction Service is not applied for, a notice stating that the filtering service is not necessary (フィルタリングサービス不要申出書) must be submitted.

●Legal representative section (The legal representative is to print their name, and affix their seal or signature.) Name of Legal Representative (guardian etc.)

Katakana Seal or signature Relationship 印

Address 〒 － Contact phone number*9

( ) －

●Subscriber (minor, etc.) section (The legal representative is to complete this section.)

Name of Subscriber (minor etc.)

Katakana

Date of birth (Year)__________ (Month)______ (Day)______ Age

Address 〒 －

*1. If a Xi packet flat-rate service or Xi data plan is used and consent is given for the subscriber (minor) to apply to remove the 128 kbps communications restriction, the subscriber (minor) will be able to apply on their own any time thereafter to remove the 128 kbps communications restriction on the 料金の確認・お支払い (Check and pay charges) page of My docomo (PC or sp-mode version). To limit consent to one application only, please state your intent in the Requested Procedure box.

*2. If giving consent for a procedure related to docomo Hikari, please enter the mobile phone number to be designated or already designated for this service. It is not necessary to enter this number if the subscriptions to docomo Hikari and the mobile phone to be designated are made simultaneously.

*3. If you choose DOCOMO’s installment payment option, your payment method must be by bank account transfer or credit card. *4. If the subscription is in an individual’s name and DOCOMO’s installment payments will be used to purchase a product costing more than ¥100,000 (incl. tax), DOCOMO will confirm the

information required for the screening process (size of family, whether living together, income/loan status, payment of home loan/rent). *5. For FOMA service subscribers only. Furthermore, the subscriber must agree to use the applicable handset for 24 months, based on the Basic Course stipulations. If the model is changed,

subscription is cancelled, etc. within this period, the Basic Course cancellation fee (¥630 [incl. tax] × no. of remaining months) will apply. *6. Access Restriction Service is a service to restrict access to sites such as dating sites and harmful sites (application required / no monthly charge). In principle, application for this service

is required in accordance with the implementation of the Act on Secure and Safe Internet Use Environment for the Youth. Furthermore, if no selection is made, intention to apply for i-mode Filter/sp-mode Filter/BlackBerry Web Filter will be assumed and the service will take effect.

*7. The Limit password is required when configuring settings for billing plans with a limit function, Access Restriction Customizer, etc. If a Limit password is already in use, a new password will not be registered. Users who know their Limit password will be able to change which sites can be accessed, raise the usage limit, etc. on their own. Therefore, legal representatives should change the password at the Limit Service Center as necessary. Please keep the password safe.

*8. Through Internet use, young people may be exposed to potentially harmful information detrimental to a healthy upbringing. Please bear this in mind if you do not use or plan to stop using Access Restriction Service.

*9. The legal representative may be contacted for confirmation at the time of application. ◆Please be sure to check the DOCOMO website, pamphlets, etc. about products and services when filling out this form. If you have any questions, please inquire at a docomo Shop or call

the docomo Information Center (0120-005-250). ◆Please be aware that mobile phone service may be suspended or the contract may be cancelled if information on this form is found to be false.

×××× ×× ××

タロウ ケイタイ

Taro Keitai

××× ×××× ×××× ×× ××

Hanako Keitai ハナコ ケイタイ

××× ××××

Please enter the date this Letter of Consent was completed.

Please select either “1. New Mobile Phone Subscription” or “2. Other (model change, etc.)” from the “Requested Procedure” section, or select both.

For “1. New Mobile Phone Subscription”, also enter the number of lines to be applied for.

If “2. Other (Application for model change, docomo Hikari, etc.)” is selected, please enter the service name and the specific procedure requested, such as “application”, “change”, or “cancellation.” Please also make sure to enter the mobile phone number subject to the request. If applying for docomo Hikari, please enter the telephone number to be designated or already designated for this service.

If nothing is selected in the “Application for Access Restriction” field, it will be regarded that an application for i-mode Filter, sp-mode Filter, and BlackBerry Web Filter has been made. Please be sure to select the applicable option. If you wish to use Access Restriction Customizer or sp-mode Filter Customizer, please enter a Limit password (a six-digit number of your choice).

Must be completed by the legal representative (guardian, etc.).

Please select a payment method when purchasing a mobile phone.

Please check “Agree” if you agree to the use of installment payments for the purchase of a product costing more that ¥100,000 (incl. tax), or “Do not agree” if you do not agree to the use of installment payments for such a purchase.

2015.2版

【弊社使用欄 / For Office Use Only】

販売店名 連 絡 先

確認欄

同意書（英語版）

Tokyo-to, Chiyoda-ku, Nagato-cho ×－×－×

Tokyo-to, Chiyoda-ku, Nagato-cho ×－×－×

*Seal or signature is not required if the name is handwritten by the representative. *Seal or signature is required if the name is inscribed by other means (rubber stamp, printer, etc.).

Father