Data Subject Request Form
Recently Updated: January 2020
DATA SUBJECT REQUEST FORM
For the purpose of this form Personal Data shall include Personal Information.
Full Name: ________________________________
Address (including ZIP): ______________________
Email Address: _____________________________
Phone Number: ____________________________
Please check the applicable box:
- I would like to receive information of why and how you are processing my information.
- I would like to receive a copy of the personal data you process on me.*
- I would like you to delete the personal data you hold on me.
- I would like you to stop processing my personal data.
- I would like to receive a copy of my data and transfer it to a third party.*
- I would like you to stop sending me direct marketing.
- I want to withdrawal my consent for processing my personal data (applicable under the GDPR).
- I would like to object to the processing of my personal data (applicable under the GDPR).**
- I believe the data you hold on me is incorrect and I would like to correct it (applicable under the GDPR).
Substantiate the request- please provide additional information about your request: __________________________________________________________________________________________________________________________________________________________________________________
What is your relationship with us (consumer, user, customer, partner, etc.): ______________________________________________________________________________________________________________________
Verification of Identity
In order to keep the privacy of individuals safe we need to make sure you are indeed who you say you are, for this reason we need to verify your identity.
Please upload or provide use with a photo ID document (i.e., driver license, passport).
For users exercising their rights under the CCPA:
Please provide proof of address so we can confirm you are a California resident (upload one of the following: utility bill, bank statement, driving license, or tax document)
Thank you for filling in the form, we will process the request by the time specified in the Data Protection Law, we reserve the right to extend the aforementioned period by the time specified in the Data Protection Law if the request is complex or numerous or we require additional information.
The processing of the request is free of charge; however, we may want to reserve the right to charge a reasonable fee to cover certain administrative costs (such as providing additional copies of the data) or for handling manifestly unfounded or excessive requests
*Under the CCPA your rights only apply to the Personal Information (as defined therein) collected 12 months prior to the request and you are not entitled to submit more than 2 requests in a 12 months period.
***Note: To submit please print and email this form to: email@example.com.***