SUBJECT ACCESS REQUEST FORM
You should complete this form if you would like us to supply you with a copy of any data we hold about you. If you are located in the European Union, or if the EU’s General Data Protection Regulation (“GDPR”) otherwise applies to your data as processed by us, you are entitled to receive this information and we will endeavor to respond promptly within 30 days of the following: our receipt of your written request; or our receipt of any further information we may ask you to provide to enable us to comply with your request.
The information you supply in this form will only be used for the purpose of identifying the person making the request and responding to your request.
1. Details of the person requesting information
Title: Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other: ☐
Legal name:
Current address:
Telephone number:
Email address:
Date of birth:
2. Are you the data subject?
☐YES: I am the data subject, I include proof of my identity.
☐ NO: I am acting on behalf of the data subject. I have enclosed the data subject’s written authority and proof of the data subject’s identity and my own identity.
To ensure we are releasing data to the right person we require you to provide us with proof of your identity (e.g. passport, driver’s license, ID card, birth certificate) and of your address (e.g. utility bill, bank statement (no more than 3 months old), local authority tax bill, tax documentation). Please supply us with a photocopy or scanned image (do not send originals to us).
3. Details of the data subject (if different from section1)
Title: Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other: ☐
Legal name:
Current address:
Telephone number:
Email address:
Date of birth:
4. What information are you seeking?
Please describe the information you are seeking. In order for us to handle your request as quickly and efficiently as possible, please provide relevant details you think will help us to identify the information you require.
Declaration I, ___________________, the undersigned and, if I am not the data subject, the person identified in Section 3 above, hereby request that BLT Innovations, Inc. provide me with the data about me identified above.
Signature:
Date:
Please return the completed form to:
BLT Innovations, LLC
PO Box 21121
Seattle, WA 98101
Email: [email protected]
