Consumer Request Form

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Select the type of request you are submitting(Required)

Request to Know Personal Information Collected/Used/Disclosed

Request to Access Specific Pieces of Personal Information

Request to Delete Personal Information

Request to Not Sell

Request to Correct

Request to Object to Processing My Personal Information

Request to Restrict Processing of My Personal Information

File an Appeal

Select one of the following(Required)

I am making this request for myself

I am authorized to submit this request on behalf of the individual listed above

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