Parental consent form (for minors from 12 to 19 by Breathe Carolina


									To KDDI Corporation                                                             Parental consent form (for minors from 12 to 19 years of age)                                                                           Date of application: year                     month               day

                                                                                                                                                                                                                            *    The 9-digit number on the top right of your service application form.
Signature of applicant (minor)                                                                                                                                                                                              number*
     Contract Applicant


                                              Name                                                                                                                                                      Date of birth
                                                                                                                                                                                                                            year / month / day

                                                                                                                                                                                                             Age                                                         years old

Signed/sealed consent of parent/guardian                                                                   (to apply for filtering services specified below)

                                              Furigana                                                                                                                                                   Relationship

                                                                                                                                                                                                        Date of birth

                                                                                                                                                                                                                            year / month / day


                                                                                                                                                                                                   TEL (                     )                            –
  Parent or guardian (legal representative)

                                              Filtering service (such as EZ Safety Access Service)

                                               (1) Application for new or transferred contract
                                                                                                                                                                                                                    0: Customized course (subject to fees)
                                                     Application for EZ Safety Access Service        Please fill in this section to apply for EZweb.                                                                 1: Service with limited connections
                                                                                                                                                                                                                    2: Service limited to specific categories
                                                   If you do not fill in this section, “1. Service with limited connections” will be selected. If the minor is a student, “2. Service limited                       x: No subscription
                                                   to specific categories” will be selected.

                                               (3) Application to change filtering service
                                                   Please fill in to apply for any of the following filtering services.
                                                   (Please checkmark where appropriate           .)

                                                Checkmarks                        Action                                                                                                        Filtering service
                                                                                                                          Without filtering service
                                                                1. New application for EZweb
                                                                                                                          (EZ Safety Access Service, etc.)

                                                                                                                             Change to EZ Safety Access Service with customized course (subject to fees)
                                                                                                                             Change to EZ Safety Access Service with limited connections
                                                                2. Change current service
                                                                                                                             Change to EZ Safety Access Service with limited categories
                                                                                                                             Change to Limited usage for EZweb access

                                                                3. Stop current service                                   Stop or limit usage of EZweb or EZ Safety Access Service

                                                                                                                          Initialize the password for EZ Safety Access Service (customized course).
                                                                4. Initialize password                                      The applicant’s birth date becomes the new password following initialization. (example: January 1st, 2000 = 20000101).

As legal guardian, I agree to the following conditions marked with a circle.
             Please place a circle in the parenthesis next to the appropriate text (1), (2), (3), or (4).

                                              (1) New or transferred contract
                                              I hereby grant permission for my child (or the minor in my care), named on the left, to enter into a service contract based on au telecommunication service agreement clauses. This includes various
                                              agreements concerning change of price plans, change of model, execution of au BOX contract, and au telecommunication services (excluding change of phone numbers and change/termination of
                                              filtering services such as EZ Safety Access Service). If the applicant has agreed to purchase a mobile phone via installment plan, I agree in advance to pay any remaining unpaid amount in a lump sum
                                              at the end of the agreed upon term. If the applicant pays for au telecommunication service usage fees with my credit card, I claim responsibility for payment. And if payment is delayed, I will make
                                              maximum effort to hasten payment.
                                              (2) Model change, extension of terminal usage, suspension of service, or Loss or Theft
                                              Coverage Service.
                                              If the applicant has agreed to purchase a mobile phone via installment plan, I agree in advance to pay any remaining unpaid amount in a lump sum at the end of the agreed upon term. (If you mark (2),
                                              please mark (3) as well if filtering service conditions are being changed.)
                                              (3) Application to change filtering services
                                              I consent to the applicant applying for EZweb, change/termination of filtering service, and password initialization.
                                              (4) Application to change telephone number.
                                              I consent to the applicant applying to change the telephone number of his/her au mobile phone.
                              Our service allows the applicant to directly apply for various services by mobile phone.

( ) The service provider offers 3 types of filtering services that prevent young people from viewing improper sites. Please visit an au shop or see catalogs, etc. for more details on these EZ Safety Access Services. If an applicant
 under 20 years old requests changes/termination of EZ Safety Access Service, we require the parent/guardian to sign a document of consent (see section 3) at an au shop or PiPit.

[Note] 1. If the applicant is 12 to 19 years old, the parent/guardian must sign each application form or this document of consent. 2. After receiving a signed application for a new contract with a minor, (or handover of utilization
 rights), the service provider will send the official letter of confirmation to the parent/guardian and may also call the parent/guardian for confirmation. 3. To make monthly payments using the parent’s/guardian’s credit card, the
 applicant must be less than 20 years old and be accompanied by the same parent/guardian at the time of application. 4. This document of consent is only effective if accepted within 1 month of being signed. 5. Any false
 information in the contract (name, address, contact address, etc.) may be cause for cancellation of the contract.

[For shop use only]                                                                                                                                                                                                                         code
 Dealer name

 Person in charge

 Special instructions

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