Personal Information Request Form

AloeVita

California Consumer

 Personal Information Request Form

 

☐ I confirm that I am a California consumer as defined in section 1798.140(g) of the California Consumer Privacy Act.

 

Please check the applicable box	Personal Information Request	Verification Any of the following pieces of information may be provided below to fulfill your request: Name, email address, or phone number.  We reserve the right to ask for additional pieces of information to fulfill your request.
☐	Please disclose the categories of Personal Information that AloeVita currently retains about me.	1. ____________________________ ______________________________ 2._____________________________ _______________________________ (2 pieces of information required)
☐	Please disclose the specific pieces of Personal Information that AloeVita currently retains about me.	1. ____________________________ ______________________________ 2._____________________________ _______________________________ 3._____________________________ _______________________________ (3 pieces of information required)
☐	Please delete my personal information.	1. ____________________________ ______________________________ 2._____________________________ _______________________________ 3._____________________________ _______________________________ (3 pieces of information required)

 

I declare under penalty of perjury that I am the consumer whose personal information is the subject of this request and whose information is contained within it. 

 

Printed Name:  _______________________________________________________________

Signature:  ___________________________________________________________________

Date:  _______________________________________________________________________

Address:  ____________________________________________________________________

Phone No.:  __________________________________________________________________

Age: ________________________________________________________________________

 

I declare under penalty of perjury that I am the authorized agent of the consumer whose personal information is the subject of this request. A notarized statement containing my signature and the signature of the consumer I represent is attached to confirm my authority to make this request.

 

Agent Printed Name:  __________________________________________________________

Agent Signature: ______________________________________________________________

Date:  _______________________________________________________________________

Address:  ____________________________________________________________________

Phone No.:  __________________________________________________________________

Age of Consumer: _____________________________________________________________

 

How would you like to receive the information you have requested:

☐ Email  

☐ Mail

 

Please provide the address where we should send the requested information:

 

Name: ________________________________________________________________________

 

Email Address: _________________________________________________________________

 

Physical Address: _______________________________________________________________

 

             _______________________________________________________________