CCPA – Data Request Form | Exela Pharma Sciences

Are you a California Resident? *

I am a *

If you selected Other, please describe your relation with Exela Pharma Sciences

I am making this request for myself or on behalf of someone else *

If you selected “On Behalf of someone else”, please complete this section.

Are you authorized to make this request?

Relationship to the person on whose behalf you are completing this form

Authorized Agent Name:

Authorized Agent Email:

Authorized Agent Contact Number:

Please note that Exela Pharma Sciences may contact you to for additional information for verification purposes.

First Name *

Last Name *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Request Type *

The categories of personal information that the business collected about me
The categories of personal information that the business sold about me and the categories of third parties to whom the personal information was sold, by category or categories of personal information for each category of third parties to whom the personal information was sold.
The categories of personal information that the business disclosed about me for a business purpose.

Action Type *

Additional information about your request

CCPA – Data Request Form