California Consumer Privacy Act Request

California Consumer Privacy Act Request

Name:*

I am or have been in the last 12 months a California resident:*

Yes

Street Address*

City*

State*

Select or enter value

Zip Code*

Email*

Phone Number*

Please describe in what capacity or context you have interacted with us to date in which you may have provided personal information to us:*

[Check All Boxes that Apply]

Select or enter value

Other; please specify:

Type of Request*

Request to Know

Access Request

Request to Correct

Request to Limit Use and Disclosure of Sensitive Personal Information

Request for Deletion

Request to Opt-Out of Sale/Sharing of Personal Information

Request to Withdraw from Financial Incentive Program

Request to Know*

Categories of personal information collected from or about me since 1/1/2022;

Categories of sources from which the personal information was collected;

Business purpose for which the personal information was used and;

Categories of third parties to which the personal information was disclosed since 1/1/2022.

Yes

Please provide me with the specific pieces of personal information collected from or about me since 1/1/2022*

Yes

Please correct personal information you have collected from me.*

Yes

Please enter a short description of the personal information you believe is incorrect, using the box below.*

Please enter the correct personal information in box below.*

Are you sure you want us to correct the personal information that you have identified?*

Yes

Please limit your use and/or disclosure of my sensitive personal information to only those purposes expressly prescribed by the California Privacy Rights Act.

Yes

Please delete all personal information that you have collected from me.*

Yes

Are you sure you want us to permanently delete all your personal information that we have collected from you?*

Yes

Request to Opt-Out of Sale/Sharing of Personal Info*

Please select all that apply:

I do not want my personal information to be sold. Please cease and refrain from selling my personal information.

I do not want my personal information to be shared with a third party for cross-context behavioral advertising purposes. Please cease and refrain from sharing my personal information for such purposes.

This request has been submitted through an agent:*

Yes

Agent's Contact Information*

Agent's Name, e-mail address and phone number:

This agent has been authorized in writing to submit this request:*

Yes

Send me a copy of my responses

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