Consumer Data request

First Name*
Last Name*
EMAIL ADDRESS*
Mobile Phone Number*
Zip Code*
SELECT PREFERRED STORE*
Password requirements
New password must meet the following:
- At least one digit (0-9)
- At least one lowercase character (a-z)
- At least one uppercase character (A-Z)
- At least 10 characters in length, but no more than 24
Password*
RE-ENTER PASSWORD*
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CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

* Required Fields
Nature of Request (i.e., what would you like us to do?)*
- Give me access to the information collected about me
- Request to correct information
- Delete my information
Consumer Name*
First Last
Consumer Email*
Consumer Mobile Phone
Enter information that you need corrected
Consumer Address*
Street Address Address Line 2 City State ZIP Code
Please describe the nature of Consumer’s relationship with Company*
- Customer
- Employee
- Former Employee
- Uncertain
Are you completing this request on behalf of another individual?*
- Yes
- No
*
If Yes, please provide your name, email address, mailing address, and phone number. Please attach documentation showing the Consumer’s authorization (if Consumer is over 18).
- I am the legal parent/guardian and the Consumer is under 18.
- I have legal authority to act on behalf of this individual.
- I am duly authorized by the Secretary of State to submit requests on behalf of others, and the consumer has authorized me to act on their behalf.
For the protection of our customers, it may be necessary for us to request additional details, including a government-issued photo ID, to confirm your identity before we act on your request. We will contact you by email if this is necessary. We will not use personal information submitted for the purpose of a Consumer Data Request for any purpose other than to effectuate your request.
Antispam
Comments
This field is for validation purposes and should be left unchanged.