7401 104th Avenue, Suite 100, Kenosha, Wisconsin 53142

Consumer Access Request Form

* indicates a required field

First Name ^*

Last Name ^*

Date of Birth (Day) ^*

Date of Birth (Month) ^*

Date of Birth (Year) ^*

Email Address ^*

Phone ^*

Address ^*

City ^*

State ^*

Zip Code ^*

Information Being Requested

Specific pieces of personal information, collected or shared with third parties and for what business/commercial purpose.Request to delete data.

We do not sell personal information that we have collected from consumers to any third parties. By completing this form, you are making a Consumer Access request under California Consumer Privacy Act for personal information collected, held and disclosed about you that you are entitled to receive. On this date [today_date], I affirm that I am the consumer, or authorized by the consumer to act on their behalf. I understand that misrepresentation may be subject to legal action.