California Consumer Request Form – Request for Categories of Personal Information

SECTION 1. NAME AND CONTACT INFORMATION

Please provide your information and sign below. Fields with an asterisk ("*") are required in order to complete the form.
First Name*

Last Name*

Common Aliases
(including previous surnames, maiden names, nicknames)

Any business or fictitious business name associated with you

Phone number*
(Please use the XXX-XXX-XXXX phone number format)

Email*

Street Address*

City*

State*
Must be California address to be eligible base on the California Consumer Privacy Act (CCPA)

Zip code*

Are you an applicant for employment or a current or formal employee of Optio Solutions?*

We may contact you if the scope of your request is unclear or does not provide sufficient information for us to conduct a search (for example, if you request "all information about me"). We will begin processing your request as soon as we have verified your identity and have all the information we need to locate your personal information. If we are unable to verify your identity, we will deny the request and inform you of the reason.
By providing us your mailing address, telephone number (including cellular numbers), or e-mail address, you consent to us contacting you by any such method.
SECTION 2. CATEGORIES OF INFORMATION YOU ARE REQUESTING
To help us understand and respond to your request quickly and efficiently, please provide as much detail as possible about the personal information you are requesting to know or delete in the box below. Please include names, dates and time frames, descriptions, documents, or any other information to help us locate your personal information.
Information you are requesting*

SIGNATURE AND ACKNOWLEDGEMENT
I acknowledge that the information provided on this form is correct and that I am the person whose name appears on this form.
By entering your full name and today's date, you are formally agreeing to the above statements*

Today's Date*