DATA RIGHTS REQUEST FORM

(UNDER APPLICABLE DATA PROTECTION LAWS)

I am: (select one)*

Request Type:*

Request*

Consumer First Name*

Consumer Last Name*

Residence of Consumer (indicate State)*

Consumer Mailing Address (Line 1)*

Consumer Mailing Address (Line 2)

Consumer Email Address*

Agent First Name*

Agent Last Name*

Agent Mailing Address (Line 1)*

Agent Mailing Address (Line 2)

Agent Email Address*

An Authorized Agent is required to provide a copy of the consumer's written authorization (for example, a power of attorney) indicating that the consumer has granted the agent the authority to submit a data rights request on behalf of the consumer.

By clicking the “Submit” button, you confirm that the information you have provided is true and accurate. Emson has the right to contact you to verify your identity, the authority of an authorized agent and to process your request.

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