Personal Information Request Form for CA Residents

This form is provided to enable California residents to exercise their rights to make requests under the California Consumer Privacy Act (CCPA). The following individuals may submit a request:

A California resident on their own behalf
A California resident on behalf of their minor child(ren)
An Authorized Agent on behalf of a California resident.

Submitter*

For oneself

As an authorizing agent

On behalf of a minor child

First Name of Authorized Agent*

Last Name of Authorized Agent*

First Name of Minor Child*

Last Name of Minor Child*

First Name of Consumer*

Last Name of Consumer*

Primary Email Address*

Additional Email

Mail Address Line 1*

Mail Address Line 2

City*

State*

ZIP Code*

Please indicate your authority to act on behalf of the California resident *

Authorizing agent type

Registered with the California Secretary of State and authorized by the California resident to act on their behalf

Acting under a Power of Attorney from the California resident

Acting as a conservator for the California resident

Authorized Agents must provide 3 items to verify their identity, one of which must be a currently valid, government-issued identification, such as a passport, driver’s license, state-issued identification card, military ID card, or permanent resident card (i.e., green card). Documents can also be emailed to [email protected]

Type of request

You may submit multiple types of requests on the same day. However, a separate form is required for each type of request.

Type of request*

Disclose categories of personal information collected about me

Disclose specific personal information collected about me

Delete personal information collected about me

Correct inaccurate personal information about me

From

Input the start date range for which you are making the request. Cannot be earlier than 01/01/2022.

Input the end date range for which you are making the request. Cannot be later than the date you submit this form

No later than 10 business days after you submit your request, we will confirm that we received it and let you know how we will process it. We will send that confirmation to the Primary Email Address you provided above. All fields with an asterisk (*) are required.

Personal Information Request Form for California Residents

Type of request

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