Verifiable Consumer Demo

1. Name and Contact Information
Please provide the Resident’s information below. If you are making this request on the Resident’s behalf, you should also provide your name and contact information in Section 3.
We will only use the information you provide on this form to (i) identify you and the personal information you are requesting access to, (ii) respond to your request and (iii) keep a record of your request and our response.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
2. Proof of Resident’s Identity
We must verify your identity before we can respond to your access and/or deletion request. We will use the information provided above to verify your identity, but we may request additional information from you to help confirm your identity and to exercise your rights state law. We reserve the right to refuse to act on your request if we are unable to identify you, and will notify you in the event that we cannot identify you.
3. Requests Made by an Authorized Agent on a Resident’s Behalf
Please complete this section of the form with your name and contact details if you are acting as an authorized agent on the Resident’s behalf.
Authorized Agent first and last name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your relationship to the Resident (for example, solicitor, other adviser, parent, or caregiver)?
Do you have legal authority to request the Resident’s personal information?

YesNo
We may request additional information from you to help confirm the Resident’s identity. We reserve the right to refuse to act on your request if we are unable to identify the Resident or verify your legal authority to act on the Resident’s behalf, and will notify you in the event that we cannot identify the Resident or verify your ability to act on the Resident’s behalf.
4. Resident Request
Please indicate your state and country of residence
Please select from the following request categories (check all that apply). I would like to exercise my right to

Access and receive my personal informationDelete my personal informationOther
Other category
To help us process your request quickly and efficiently, please provide as much detail as possible about the personal information you are requesting access to or to have deleted from our systems. Please include time frames, dates, names, types of documents, file numbers, or any other information to help us locate your personal information.
We will contact you for additional information if the scope of your request is unclear or does not provide sufficient information for us to conduct a search. We will begin processing your request as soon as we have verified your identity and have all of the information we need to locate your personal information.
The personal information you request will be mailed to the home or email address you provided above. If you have a question please contact us at privacy@cookandboardman.com or Cook & Boardman Group, LLC Attention: Privacy Inquiries, 3064 Salem Industrial Drive, Winston Salem, NC 27127.
If we cannot provide you with access to or delete your personal information, we will inform you of the reasons why, subject to any legal or regulatory restrictions.
Our Privacy Policy and Notice at Collection is available at Privacy & Policy.
Acknowledgment
I confirm that the information provided on this form is correct and that I am the person whose name appears on this form either as the Resident or Resident’s Authorized Agent. If I am the Resident’s Authorized Agent I confirm that I am authorized to act on behalf of the Resident. I understand that CBG must verify my identity and in the case of Authorized Agents, my legal authority to act on the Resident’s behalf, and may need to request additional verifying information. My request will not be valid until CBG receives all the required information to process the request.
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

1. Name and Contact Information

2. Proof of Resident’s Identity

3. Requests Made by an Authorized Agent on a Resident’s Behalf

4. Resident Request

Acknowledgment