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:
Please provide the address where we should send the requested information:
Name: ________________________________________________________________________
Email Address: _________________________________________________________________
Physical Address: _______________________________________________________________
_______________________________________________________________
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