委任状（英語併記版）（PDF/75KB）

※ 委任状は、お手続きを委任する方がすべて自筆でご記入ください。
The person who delegates the requests must complete the entire letter of proxy with his/her own hand.
委任状
Letter of Proxy
(Date)
次の取り扱いを委任します。I delegate the request as follows.
郵便番号
Postal Code（
－
）
Address
印
Seal/Signature
Delegator (account holder)
委任者（名義人）
おところ
おなまえ
Name
受任者（代理人）
Delegatee (proxy)
郵便番号 Postal Code（
－
）
おところ
Address
おなまえ
Name
Note: For passbook-type Teigaku and Time deposit, or
Collateral deposit, please write the certificate numbers
contained in the passbook. For National Government bearer
bonds, please write the individual number on each bond.
* Please check the appropriate boxes below.
* Please circle the delegated service in brackets.
Check
委任する内容
記号番号
Delegated service
Code number
Certificate
number, etc.(Note)
（額面）金額
(Face value) Amount
□
Withdrawal of (通常 Ordinary deposit/
定額 Teigaku deposit/ 定期 Time deposit/
)
Yen
□
Withdrawal of (通常 Ordinary deposit/
定額 Teigaku deposit/ 定期 Time deposit/
)
Yen
□
Change of (住所 address/ 氏名 name/ 印章 seal )
□
Request for reissue of a passbook, etc. due to loss, etc.
□
紛失等による通帳等の再発行請求
暗証番号照会 Inquiry about a PIN/ 暗証番号誤回数消去
Request to reset the number of incorrect PIN entries
□
□
* Please fill in the section below when requesting items regarding registered National Government bonds.
Check
委任する内容 Delegated service
記号 Code
国債名称 Name of Japanese Government bond
□
国庫債券 Japanese Government Bond
額面金額
(Face value) Amount
証券番号 Certificate number
Yen
受
□確認年月日
年
月
□確認時刻
時
分
【規程 Navi ｺｰﾄﾞ：52593 改正年月：2014.4】
日
付
考
委任確認
備
＜For office use＞
日附印
(Note)
 The delegator must affix the registered seal or sign in the “seal/signature” column.
(If the request does not require a registered seal, the delegator may use any of his/her seals.)
 For requests regarding National Government bearer bonds, the delegator must also write his/her passbook
number in the “Code number” column.
 A proxy following the request based on this letter of proxy must bring his/her seal and identification documents
issued by public agencies that include the proxy’s name and address.
Depending on the delegated service, the proxy may also be required to affix delegator’s seal to other documents
and present identification documents issued by public agencies that include the delegator’s name and address.
 We may contact the delegator in person by phone to confirm the delegated service when accepting the request
from the proxy. Please note that in the case that we cannot confirm the delegation, we cannot accept the request.

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