CCPA Agent Request Form

The CCPA allows you to designate an Authorized Agent to act on your behalf, including to submit requests. Please fill out the below form:

California Authorized Agent Designation Form

The CCPA allows you to designate an Authorized Agent to act on your behalf, including to submit requests. Please fill out the below form:

Consumer Information

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Authorized Agent Information

First Name Last name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Deliver Information Requested by Agent:

to me, the Consumer

to my Authorized Agent

Allow My Authorized Agent to Make (select all that apply):

Access Requests

Deletion Requests

Portability Requests

Consumer Authorization
By signing below, you give your full authorization for the above-mentioned individual to be your Authorized Agent, as permitted under the CCPA.

Signature

Date
MM slash DD slash YYYY

Email
This field is for validation purposes and should be left unchanged.