California Data Subject Request Form

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California Data Subject Request Form

Website users may use this form to submit requests regarding personal information collected by Anavasi Diagnostics dba Anavasi (“Anavasi”).

We reserve the right to refuse requests, in whole or in part, to the extent permitted by law, including due to an inability to verify your identity or verify your authority to act on behalf of the consumer who is the subject of the request. For certain requests, we may ask for additional information or documents for verification purposes.

Anavasi will use the information you provide through this form to respond to your request, including verifying identify, identifying personal information responsive to your request, and keeping records of your request.

California Data Subject Request Form

Name

First Name

Last Name

Street Address (Mailing)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

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

YES

Requester’s Information*

I am the consumer and am making a request related to personal information about me.

I am not the consumer and am acting as an authorized agent for the consumer. I have enclosed a completed Agent Designation Form completed and signed by the consumer to this Request.

Request for Online Activity Information

If your request applies to online activity information Anavasi may have collected through cookies or similar technologies, you must make your request form the browser or device that you previously used to access Anavasi’s Website located at http://www.anavasidx.com. This allows us to read any identifier that we or our service providers may have assigned to your browser or device. Specification of Request

I am requesting a Do Not Sell.

I am submitting a Request to Know.

I am submitting a Request to Delete the personal information Anavasi has collected about me.

Right to Rectify.

Consumer's Name

By submitting this form, I hereby certify that the information entered into this form is complete and accurate, and that I am the consumer who is the subject of the request or have been authorized by that consumer to act on they/his/her behalf, as indicated above. I understand that Anavasi may need to request additional information in order to verify the identity of the consumer and/or authorized agent for this request.

First Name

Last Name

Date

YYYY