Name *

First Name

Last Name

I am a California Resident or I am authorized to make this request by a current resident of California *

Yes

No

I am Requesting *

Do not sell or share my personal information

Opt out of the sale or sharing of my personal information

Limit the use of my sensitive personal information

Change my information that may be inaccurate

Date

MM

DD

YYYY

I confirm that I am the person identified in this form, I am a current resident of California, or I am authorized to make this request by a current resident of California, and all of my information is true

Yes

No