Authorized Agent Designation Form
AUTHORIZED AGENT DESIGNATION FORM
Instructions: If you are a resident of California and would like to designate an authorized agent to submit a request on your behalf related to your Personal Data, please complete this form in its entirety. A signed copy of this form must be attached to the data subject request you submit to us.
Please note that, if we are unable to verify the identity of the individual submitting this form (the “Data Subject”) we may ask for additional information or documents for verification purposes. For more information please see our Privacy Policy.
- Data Subject Information
Full name of Data Subject:
Mailing address of Data Subject:
Email of Data Subject:
Phone number of Data Subject:
- Authorized Agent Information
Full name of Authorized Agent:
Mailing address of Authorized Agent:
Phone number of Authorized Agent:
Authorized Agent’s California Secretary of State’s Registration Number (if applicable):
- Authorization
I, Data Subject, designate the Authorized Agent listed above for the sole purpose of submitting the following request(s) on my behalf (check all that apply):
___ Request to delete my Personal Information; and/or
___ Request to access my Personal Information
By signing below and submitting this Authorized Agent Designation Form, I affirm the following:
- I am, or was in the last 12 months, a resident of California.
- I am the Data Subject whose name appears above and the information provided in this form is true and accurate.
- The Authorized Agent is a natural person or a business registered with the California Secretary of State to conduct business in California.
- I understand that I may be contacted directly in order to verify my identity and to confirm designation of my Authorized Agent.
- I grant the Authorized Agent permission to submit the request(s) indicated above to the Company on my behalf.
- I authorize the Company to process such request(s) and I understand that any responses produced in connection with a request to access my Personal Data will not be sent to my Authorized Agent, but will instead be sent directly to me at the address provided above.
- The authority granted by this form will terminate 90 days after the date of execution.
- I agree to defend, indemnify, and hold the Company harmless for any and all claims that arise against the Company in relation to its reliance on this Authorized Agent Designation Form.
Signature of Requestor/Data Subject:
Printed Name:
Date: