RevenueWell Authorized Agent Request – Privacy Support Services

Authorized Agent Request

Step 1 of 2 – Please Declare Your Residency

You must be an authorized agent with a license to practice in California in order to complete this form.
Are you an Authorized Agent?
- Yes
- No
Authorized agents are someone that acts on a consumers behalf. Click this only if you are submitting this form on behalf of someone else.
What is Your Client's ZIP Code?*

Type of Request (On Behalf of Client)*
Client Information
Client's First Name*
Client's Last Name*
Client's Address*
Street Address Address Line 2 City State ZIP Code
Agent Information
Agent's First Name*
Agent's Last Name*
Agent's Address*
Street Address Address Line 2 City State ZIP Code
Agent's Phone*
Agent's Email*

Third-Party Requests

Third-parties submitting requests on another’s behalf should submit a signed power of attorney or other documentation signed by the data subject on whom the request is being submitted proving the agent’s authority to submit a request on the data subject’s behalf. If provided, we will retain your documentation for no longer than necessary. We reserve the right to deny requests from persons or businesses claiming to be authorized agents that do not submit sufficient proof of their authorization. State-specific limitations may apply to requests by agents.

Authorized Agent Request

Step 1 of 2 – Please Declare Your Residency

You must be an authorized agent with a license to practice in California in order to complete this form.

Client Information

Agent Information