California Authorized Agent Designation Form

The CCPA allows you to designate an Authorized Agent to act on your behalf, including to submit requests. Please fill out the below form:

    Consumer Information

    Authorized Agent Information

    Deliver Information Requested by Agent:

    Allow My Authorized Agent to Make(select all that apply):

    Consumer Authorization

    By submitting this form, you give your full authorization for the above-mentioned individual to be your Authorized Agent, as permitted under the CCPA.