Consent Form For Statutory Agent (Web Safety Service Application

Consent Form For Statutory Agent (Web Safety Service Application Confirmation)
and Consent Form For Account or Card Holder
Applicant's Name
JUN/2011 Ver.
① To be filled by Statutory Agent when Applicant is a minor
□ I, as a statutory agent for the applicant named below (in case the applicant is a minor and two or more people have parental authority/custody,
as a representative of them), consent in advance that the Applicant will apply the checked application items in <Table 1> I acknowledge that I
am fully informed about, and agree with the application for Web Safety Service as checked in <Table 2>(Applicable only when S!Basic Pack including
S!Basic Pack(i), the same shall apply hereinafter. ) is applied).
<Table 1>◆Agreed application item (To be checked by Statutory Agent)
・Conclusion of New Contract under Terms and Conditions for 3G Communication Service(including Terms
New Contract
(including Assignment of and Conditions for SoftBank Mobile(E) Data Communication service. The same shall apply hereinafter.),
and Conclusion of Purchase Contract for a mobile phone handset or other products, Installment Purchase
Changing Handset
Please fill out <Table 2>
when S!Basic Pack is
Contract or Third Party Credit Contract for Each Commodity (collectively, "Installment Contract") for a mobile Please fill out ② below
phone handset or other products.
when necessary.
・Changing or cancelling service information regarding Terms and Conditions for 3G Communication
Service (payment plans, discount services, options, payment method etc.), termination of a contract,
temporary suspension, and changing or cancelling Installment Contracts, after the conclusion of above
※Except the application for S!Basic Pack and changing/cancelling for Web Safety Service.
Conclusion of Purchase Contract for a mobile phone handset or other products, or Installment Contracts for
a mobile phone handset or other products.
○ Change of Service
Application for S!Basic Pack or changing/cancelling of Web Safety Service for existing customers.
○ Other
Conclusion of Contract under White BB Service Agreement.
Please fill out <Table 2>
<Table 2>◆Web Safety Service application confirmation (To be checked by Statutory Agent)
There is a possibility that a user may be involved in crimes by accessing illegal and harmful websites or inappropriate use of the internet.
Please apply Web Safety Service to restrict the access to illegal or harmful websites. The internet use by minors must be monitored and supervised
by their parents/guardians at their responsibility. Please check our Website or catalogue for more detail.
If you do not wish to apply any of these services, please check
□A:Yahoo! Kids
□B:Restricted Web Filtering
※ None of the Web Safety Services or reasons are selected, B:
□C:Relaxed Web Filtering
□E:Relaxed Web Filtering Plus
Restricted Web Filtering (SoftBank 3G/Smart Phone) or A: Use of
●Please check only one service among above.
Filtering Application (iPhone/iPad) is deemed to be selected.
●For Softbank 3G, if any of Web Safety Services listed above as A through E
selected, PIN number is required when purchasing digital contents.
□1 These services interfere Applicant's work
□A:Use of Filtering Application
●You need to install a filtering application from the APP store and restrict
iPhone/iPad the functions of Safari* on iPhone/iPad by yourself.
*a browser installed on iPhone/iPad
●Please see the iPhone filtering setting manual/iPad filtering setting manual
available at shop for set up.
□2 These services interfere the usage of internet for Applicant's
disabilities or health conditions.
□3 Parents/Legal Guardian will oversee and supervise the
Applicant's safe use of the internet
□4 Other(
Date of Birth
Statutory Agent's Name
Relationship to
the Applicant
Contact Phone Number
〒 ② Mobile Phone, Daytime Contact Phone Number
( ) -
( ) -
② To be filled by Billing Account Holder when the Applicant is NOT Billing Account Holder
□ I agree as follows:
●I agree that the billing statements will be sent to my current address and contact number.
●I agree to make the following payments for the Applicant from my bank account or by my credit card when I am designated as Payer by the applican
●In the event the Applicant fails to pay any of its debts by the due date, I agree to make best efforts to settle such non-paymen
① The payment for the service charges for the Applicant under Termms and Conditons for 3G Communication Services (including Terms and
Conditions for SoftBank Mobile(E) Data Communication service.) and the payment for the purchase price or the installment payment for a
mobile phone handset and other products.
② The payment for the fees and other charges for the services, etc provided by SoftBank Mobile Corp. or other designated contractors under
the regulations regarding "SoftBank Consolidated Billing" service, for content information under the terms and conditions for web use, and
for the purchase price for "S! Pay for All (S! Matomete Shiharai)".
③ Service charge and any other fees and charges under White BB Service Agreement
●I agree that SoftBank Mobile Corp. may use my personal information for the following purposes:
① To evaluate my solvency at the time of the Contract and for the duration of the Contract.
② To send a bill or request the payments under the Contracts with the Applicant.
③ To send notices for confirmation, amendment, etc regarding the above from SoftBank Mobile Corps; or to use for any other business related
to the above.
Date of Birth
Payer's Name
(Billing Account Holder)
Address and
Contact Number
Relationship to
the Applicant
〒 -
Contact Phone Number
・SoftBank Mobile Corp. may call or mail you to reconfirm the above. If any of the parts written in this form turn out to be untrue, the subscription may be cancelled.
Please check our website and catalogue for product and service details when filling out this form. Please visit nearest SoftBank store or call SoftBank customer
support if you have any questions.
取扱店記入欄 (For shop use only) ※未成年者がお申し込みする場合、①もしくは②をご記入のうえ、署名をお願いいたします。
① 同意者の来店により、対面にて同意確認しました。
② 同意者の来店がなかったため、架電により同意確認しました。