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CALIFORNIA RESIDENTS CONSUMER REQUEST FORM
CALIFORNIA RESIDENTS CONSUMER REQUEST FORM
Consumer First Name*
Consumer Last Name*
Consumer Reply Email Address (if different than above)
Consumer Street Address
Consumer City of Residence*
Consumer State of Residence
California
Colorado
Other
Are you the consumer?*
Yes, I am making a request related to personal information about me.
No, I am acting as an authorized agent for the consumer. I have attached one of the following, completed and signed by the consumer: (1) a signed authorization of the consumer; or (2) a Power of Attorney pursuant to California Probate Code §§4121 to 4130
Attachment*
Specify the request(s) - check all that apply*
Request to know categories of personal information EG America has collected, used, disclosed, and/or sold about the consumer.
Request to obtain specific pieces of personal information EG America has collected about the consumer.
Request to delete personal information EG America has collected about the consumer.
Request to opt out of the "sale" of personal information about the consumer.
By Submitting this form, I hereby certify that this request is being made by or on behalf of a current resident of California or Colorado.*
I accept.
By submitting this form, I hereby certify under the pains and penalties of perjury that the information entered into this form is complete, accurate, and up-to-date, and that I am the consumer who is the subject of the request or have been authorized by that consumer to act on his/her behalf, as indicated above. I understand that it will be necessary for EG America to verify the identity of the consumer and/or authorized agent for this request, and additional information may be requested for this purpose.*
I accept.
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