CCPA Form

Consumer Privacy Data Request Form

By completing this form, you may be executing your right under state law. By submitting this Data Request form you are granting us permission to contact you, either by email or phone, to confirm receipt of your request and to request any additional information necessary to verify your request.

First

Middle

Last

Address

City/Town

State/Province

ZIP/Postal Code

Phone

Please describe in what capacity or context you have interacted with us to date in which you may have provided personal information to us

Employee

Job Applicant

Independent Contractor or Consultant

Website User

App User

Individual Customer (non-entity)

Service Provider, Vendor or Supplier

Other

please specify

Would you like to access Employee Workplace Injury or Illness Records?

Yes

Type of Request

Type of Request (California Residents)

Categories of personal information collected from or about me since 1/1/2022.
Categories of sources from which the personal information was collected.
Business purpose for which the personal information was used.
Categories of third parties to which the personal information was disclosed since 1/1/2022.

Please provide me with the specific pieces of personal information collected from or about me since 1/1/2022.

Request to Correct

Please correct personal information you have collected from me.

Please enter a short description of the personal information you believe is incorrect, using the box below.

Please enter the correct personal information in box below.

Are you sure you want us to correct the personal information that you have identified?

Yes

Request to Limit Use and Disclosure of Sensitive Personal Information

Please limit your use and/or disclosure of my sensitive personal information to only those purposes expressly prescribed by the California Privacy Rights Act.

Yes

Request for Deletion

Please delete all personal information that you have collected from me.

Are you sure you want us to permanently delete all your personal information that we have collected from you?

Yes

I do not want my personal information to be sold. Please cease and refrain from selling my personal information.
I do not want my personal information to be shared with a third party for cross-context behavioral advertising purposes. Please cease and refrain from sharing my personal information for such purposes.

I wish to withdraw from the Company’s financial incentive or loyalty rewards program Ambassador360. Please delete my account. I understand that by withdrawing from the program and having my account deleted, I will not be receiving any of the financial incentives, rewards, benefits or discounts that I may have previously earned or accrued as a member of this program.

This request has been submitted through an agent on my behalf:

Yes

Agent’s Name:

This agent has been authorized in writing to submit this request on my behalf:

Yes

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Contact Numbers

Consumer Privacy Data Request Form

Request to Correct

Request to Limit Use and Disclosure of Sensitive Personal Information

Request for Deletion

Company

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