Step 1 of 5
CCPA (California Residents) OCPA (Oregon Residents)
Step 2 of 5
Access InformationDelete InformationCorrect InformationDo Not Sell or Share My Personal Information
Customer/ConsumerCurrent/Former EmployeeCurrent/Former Job Applicant
MyselfOther ( I am acting as an Authorized Agent)
*If you are an authorized agent, please fill out the next steps with the consumer’s information.
Step 3 of 5
Suffix
Mr.Mrs.Dr.
First Name
Middle Name
Last Name
Date of Birth
MM/DD/YYYY
Last 4 digits of social security number or ITIN
Providing the last 4 digits of your SSN or ITIN is not required to submit a request, but will be necessary to verify your identity for a request to access specific pieces of personal information collected.
Authorized Agent First Name*
Authorized Agent Last Name*
Step 4 of 5
City
State
ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip Code
Consumer’s Phone
Consumer’s Email
Confirm Consumer’s Email
Authorized Agent Email
Confirm Authorized Agent Email
Authorized Agent Phone
Step 5 of 5
Request Details
Authorized Agents
Please use the area below to upload your authorization to act on the consumer’s behalf as part of your request submission
Requests to Correct:
Please provide details about the information you wish to be corrected in the Request Details area above and upload any documentation related to the contested information in the area below as part of your request submission.
SELECT FILE…
File larger than 4mb are not supported.
I declare under penalty of perjury that the foregoing is true and correct and that I am the consumer (or the consumer's Authorized Agent) whose personal information is the subject of this request.
Confirm/Obtain Personal Data (Consumer Only)Delete Personal Data (Consumer Only)Correct Personal Data (Consumer Only)Request a List of 3rd Parties To Which We Have Disclosed Personal Data (Consumer Only)Opt Out of Automated Decision Making (Profiling)Opt Out of Sale of Personal Data
Providing the last 4 digits of your SSN or ITIN is not required to submit a CCPA or OCPA request, but will be necessary to verify your identity for a request to access specific pieces of personal information collected.
Street Address 1*
Street Address 2
