California Consumer Privacy Act (CCPA) - Request Form

Notice: If a resident of California (“California Consumer”) would like to submit a request to know or delete personal information that we have collected, please complete and submit the following form. If you are submitting this request on behalf of yourself, we will collect your name, date of birth, e-mail address or mailing address, telephone number, and information about your relationship with us. If you are submitting this request on behalf of some other California Consumer or on behalf of the California Consumers in your household, we also will collect their names, dates of birth and information about their relationship with us. We collect this information in order to process and respond to your request. For our record keeping purposes, we will keep a copy of your request, our response and any documents you submit to us during this process. We are required to keep these records for a minimum of 24 months.

Your Information

Example: 555-555-5555

Only California Consumers are able to submit a request under the CCPA.

California Consumer’s Information

Insert the identifying information about the California Consumer whose information is the subject of the request (yours or someone else). To submit a request on behalf of some other California Consumer, we require that you provide us with a signed written permission of the Consumer authorizing you to make this request on their behalf.

Consumers in your household


If different than above
Include full address with City, State and Zip

Choose all that apply.

If the request is to know specific pieces of information collected about the Consumer or to delete personal information collected from the Consumer, we require that you submit a declaration signed under penalty of perjury from the Consumer whose personal information is the subject of this request.