CCPA Authorized Agent

First Name

Last Name

Zip or Postal Code

Email Address*

Name of Authorized Agent

Should information be sent to you or the agent?

I hereby give my authorization for the agent to make the following types of requests on my behalf:

Categories of personal information Entrust has collected, use, and/or disclosed about me

Specific pieces of personal information Entrust maintains about me

Delete personal information we collected from me

Full Name

Date

By checking this box, I confirm that my name above is intended to serve as a signature on this form

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