CCPA Agent Request Form

The CCPA allows you to designate an Authorized Agent to act on your behalf, including to submit requests. Please fill out the below form:

California Authorized Agent Designation Form

The CCPA allows you to designate an Authorized Agent to act on your behalf, including to submit requests. Please fill out the below form:
Consumer Information
Address
Authorized Agent Information
Address
Deliver Information Requested by Agent:
Allow My Authorized Agent to Make (select all that apply):
Consumer Authorization
By signing below, you give your full authorization for the above-mentioned individual to be your Authorized Agent, as permitted under the CCPA.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.