Consumer Request Form

Consumer Right to Know (Access), Delete, or Correct Form

I am submitting the following request on behalf of:*
- Myself
- On Behalf as an Individual as an Authorized Agent
Please Select the Type of Request*
- Right to Know / Access Request
- Deletion of My Personal Data
- Correction of Personal Data in Our Possession
- Opt-Out of Sale of Personal Information
Name*
First Last
Email*
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Please Indicate My Preferred Method of Communication*
- Email
- Phone / Text
- Mail
Please provide information that may be helpful in processing your request:
Information on Requestor if Different Than the Consumer Subject (Authorized Agent)
Full Name Organization Name (If Applicable) Relationship to Consumer Subject
(Continued) Information on Requestor if Different Than the Consumer Subject (Authorized Agent)
City / State / Zip Code Phone Number Email
Consent*
By submitting this request, I declare under penalty of perjury that I am the consumer or authorized agent whose personal information is the subject of this request. Prior to processing your request, we may contact you, or your authorized agent to verify your identity. The information provided will be used to process your request and will not be used for marketing purposes.*
Signature*
Date of Signature*
MM slash DD slash YYYY
CAPTCHA

Full Name	Organization Name (If Applicable)	Relationship to Consumer Subject

City / State / Zip Code	Phone Number	Email

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