California Authorized Agent Designation

Where Speed, Efficiency, & Accuracy Align

California Authorized Agent Designation

California Consumer Privacy Act

California residents have the right to designate an authorized person or corporate entity to exercise rights granted to them under the California Consumer Privacy Act ("CCPA"). To make this designation, California residents may complete and submit this form to Anavasi Diagnostics.

If we are unable to verify the identity of the person submitting this form, we may request additional information from the person making the submission. Authorized agents that have been provided a power of attorney from a consumer may submit requests directly on behalf of that consumer so long as proof of such power is submitted along with the consumer request form.

Asterisks indicate required fields.*

If designating an entity to act on your behalf, we require that such entity be registered with the California Secretary of State. Anavasi Diagnostics will not provide information to unregistered agents.

The CCPA and this Agent Designation Form applies to California Residents (including those in the immediate last 12 months) only.

California Data Subject Request Form

Consumer's Name

First Name

Last Name

Consumer's Email

Consumer's Street Address (Mailing)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consumer's Phone

(###)

###

####

Check if State of Residence is California or was in California the immediate last 12 months*

YES

Authorized Agent's Name

First Name

Last Name

Authorized Agent's Email

Authorized Agent's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized Agent's Phone

(###)

###

####

By signing below, I authorized the agent identified above to make the following types of requests on my behalf to Anavasi Diagnostics.

Request to know the categories of personal information Anavasi Diagnostics collects about me.

Request to know the specific pieces of personal information Anavasi Diagnostics collects about me.

Request to delete the personal information Anavasi Diagnostics collects about me.

Request to opt-out of the sale of my personal information

Please deliver any information requested by my authorized agent to:

MY AUTHORIZED AGENT

Date

YYYY

Consumer's Name

Please complete all the fields in this form and submit by clicking the button below.

First Name

Last Name