2016

16
04
(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.)

1. New Mobile Phone

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

<Be sure to indicate how many lines the application is for.>

1. Single line (mobile phone)

Subscription
2. Other

(Circle an option on the right.)

3. Multiple: (

) lines

Requested Procedure*1

(application for
model change,

Applicable phone number*2

docomo Hikari, etc.)

Mobile Phone
Purchase Method*3

2. Single line and 2in1

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 DOCOMOs 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.

sp-mode

sp-mode Filter

Application for Access

Restriction Service
(filtering service)*6

i-mode

(Select an option on the right if

you will use i-mode, sp-mode,
or BlackBerry Internet
Service.)

BlackBerry

BlackBerry Web Filter

sp-mode Filter Customizer

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

If applying for Access Restriction Customizer or

sp-mode Filter Customizer, set a Limit password.

Limit password*7

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 (
) must be submitted.

Legal representative section (The legal representative is to print their name, and affix their seal or signature.)
Katakana
Name of Legal
Seal or signature
Relationship
Representative

Father
(guardian etc.)
*9

Contact
phone
number
Simponi Mas IV B7 no 9 kelapa
Address
gading, Jakarta Utara,Indonesia
(+62
)8161124200

Rudy Muljono

Subscriber (minor, etc.) section

Name of Subscriber
(minor etc.)

Maria Devina Natasha

Date of birth
Address

(The legal representative is to complete this section.)

Katakana

1997
09
02
(Year)__________
(Month)______
(Day)______

Age

19

8 Chome-3-13 Uehonmachi, Tennoji Ward, Osaka, Osaka Prefecture 543-0001

*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 (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 DOCOMOs installment payment option, your payment method must be by bank account transfer or credit card.
*4. If the subscription is in an individuals name and DOCOMOs 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.
/ For Office Use Only

2015.2