Privacy Rights Request Form

Please answer the following questions to submit your request.

1. About You

Name*

Street Address

City

State

Zip

Phone Number*

Email Address

Date of Birth

How should we contact you if we have questions about your request? (check one) By mailBy emailBy phone

2. Further details

Are you the person who is the subject of this request? Yes, the personal information at issue is about me (we will ask you to confirm your identity)No, I am acting on behalf of the person who is the subject of this request with their express permission, or with the appropriate legal authority (we will ask for appropriate verification).

In what capacity are you making this request? (check one) As a customerAs an employee or contractor

3. The Request

Which right(s) would you like to exercise? Access my personal information: show me what you haveKnow categories of personal information: tell me what you haveDelete my personal information: destroy what you haveCorrect my personal information: update what you have

What specific personal information is at issue (if relevant)?

When and how did you provide us with the personal information at issue? (Any information you provide, even if approximate, will help us respond to your request)

Please tell us if your request is limited to certain dates or categories of personal information:

4. Identity Verification

Depending upon the nature of your request, we may ask for additional information or documentation so that we can verify your identity.

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