Verifiable Consumer Access and Deletion Request "*" indicates required fields Residents of certain jurisdictions (the “Resident”) may have the right to access or delete the personal information held by Cook & Boardman Group, LLC (“CBG”) about that Resident, including the right to know and access specific information or categories of information CBG may collect about such Resident, and to have that information provided to you or deleted. In order for us to respond to your request, we ask that you submit your request using the form below. We will confirm our receipt of your request within 10 days of its receipt by CBG, and we expect to respond to your request within 45 days of CBG’s receipt of a fully completed form and proof of identity. You do not have to use this form but using this form should make it easier for you to make sure you have provided us with all relevant information, and for us to process your request. 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 Name Last Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Address* 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 Name First Name Last Name Authorized Agent Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Authorized Agent PhoneAuthorized Agent Email 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? Yes No 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 RequestPlease 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 information Delete my personal information Other: Other: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.Personal Information RequestedWe 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 is available at: https://www.3sixtyintegrated.com//privacy-policy-and-notice-at-collection/ AcknowledgmentI 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.* Agree CAPTCHA Δ
