Full Name *

First Name

Last Name

Phone *

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Date of your request *

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DD

YYYY

Time of your request *

Hour

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Second

AM PM

What is your postal address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

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I am submitting this information on behalf of: *

Myself

Someone else

What is the reason for your request? *

Get a copy of my personal information /know what information is being collected from me

Edit or correct my personal information.

Restrict the processing of my personal information.

Object the processing of my personal information.

Delete all my personal information.

Using data portability.

Allow the use of my personal information for marketing or profiling.

Deny the right to use my personal information for marketing or profiling.

Other

Declaration *

I confirm the following: Under penalty of perjury, I declare all the above information to be true and accurate.

I, (full name of DS), confirm that the information provided in this form is true and accurate.

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I, (full name of the representative), confirm that I am authorised to act on behalf of the data subject. The information provided in this form is true and accurate to the best of my knowledge.

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I understand that I will be required to validate my request by email and I may be contacted in order to complete the request, check my identity and gather further information to process this request.