CALIFORNIA CONSUMER PRIVACY ACT REQUEST FORM

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BY CHECKING THE BOX BELOW, I HEREBY CERTIFY 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 MAY BE NECESSARY FOR YOU TO VERIFY THE IDENTITY OF THE CONSUMER AND/OR AUTHORIZED AGENT FOR THIS REQUEST, AND ADDITIONAL INFORMATION MAY BE REQUESTED FOR THIS PURPOSE