CCPA Authorized 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:

Please submit your request through the form below.

Consumer Information

Authorized Agent Information

Deliver Information Requested by Agent:

Allow My Authorized Agent to Make

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.