Data Privacy Authorized Agent Request Authorized Agent Request Step 1 of 2 – About the Agent 0% You must be an authorized agent with a license to practice in California in order to complete this form.About the AgentAgent Full Name(Required)Agent OrganizationAgent Email(Required) Agent Phone(Required)Proof of Authorization(Required)Attach a power of attorney or signed authorization formAccepted file types: pdf, Max. file size: 300 MB. Certification of Authorization(Required) I certify under penalty of perjury that I am authorized to submit this request on behalf of the consumer named in Step 2. Type of Request (On Behalf of Client)(Required)Request to know or access personal information the business has collectedRequest to opt-out of sale of informationRequest to delete informationClient InformationClient's First Name(Required)Client's Last Name(Required)Client's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
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