California Consumer Privacy Act (CCPA) Request form for California Residents

Who is the request for?*
- Myself
- Someone else
Consumer's name*
First name Middle name Last name
Your (Representative's) Name:*
First name Middle name Last name
Personal Phone Number*
Personal Email Address*
Confirm Personal Email Address*
Your phone number*
Your email address*
Confirm your email address*
YOUR ADDRESS*
Street address 1 Street address 2 City State Zip
In what capacity do you represent the Consumer?
What documents do you have establishing your right to act on the Consumer’s behalf?
Consumer's name*
First name Middle name Last name
Consumer's personal phone number*
Consumer's personal email address*
Confirm consumer's personal email address*
State of Residence
STREET ADDRESS- CONSUMER’S PRIMARY HOME:*
Street address 1 Street address 2 City State Zip
What is the consumer's relationship with ICW Group?*
Type of request?*
Please clarify details of your request, specify particular records or information involved, applicable dates, and any additional details that may assist us in understanding what you want to achieve and enable us to respond to your request.
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