Privacy Rights Request Form

Consumer Information

Name of Consumer (First, Middle, Last)*

Prior Name (if Applicable)

Address*

Address Line 2

City*

State*

ZIP Code*

Email address

Phone Number 1*

Phone Number 2

Requester Information

If you are both the consumer and requester, please skip to the next section.

Name of Requester (First, Middle, Last)

Relationship to Consumer
Family MemberTrusteeAttorneyBrokerAgentOther

If other, please explain

Address

Address Line 2

City

State

ZIP Code

Email address

Phone Number 1

Phone Number 2

If you are requesting information as an authorized agent, additional documentation will be required, and we will contact you about your request.

Consumer Type

To help us respond to your request, please indicate your consumer type.*
AdministratorStudentParentOther

Other

Request Type

Please indicate the type of request you would like to make.*
Right to Access/PortabilityRight to Deletion/ErasureRight to Correction/RectificationRight to Restrict Processing/Limit ProcessingRight to Object to ProcessingWithdraw ConsentOpt-Out of Targeted Advertising/Sale/Sharing of Information

Please indicate the Personal Information you would like limited

Preferred method for responding to your request.*
EmailU.S. Mail

By selecting the submit button below, I declare under penalty of perjury that I am the consumer whose Personal Information is the subject of this request or an authorized requester on behalf of such consumer.