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California Consumer Privacy Act
Are you submitting this request (as an authorized agent) on behalf of someone else?
- Choose One -
No
Yes
Agent Information:
First Name:
Last Name:
Phone Number:
Email:
Contact Information:
Name:
*
First Name:
*
Last Name:
*
Street Address:
*
Address 2:
City:
*
State:
*
- Choose Your State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
*
Phone Number:
*
Email:
*
Preferred contact method?
*
- Choose One -
Phone
Email
Either
CCPA Information Request:
What would you like to do with your Personal Information?
*
- Choose One -
Tell me the categories of personal information you have on file about me
Tell me the specific pieces of information you have on file
Correct my personal information
Delete my personal information
Other
Other:
Comments/Questions:
By checking the box below, I give my electronic signature and certify that I am the above named individual or authorized agent for the named individual. I am submitting this form on my own behalf or I have been duly authorized by the above-named consumer to submit this form on their behalf.
*
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
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