Privacy Request Form - Millicent Pharma

The California Consumer Privacy Act provides California residents with rights
related to personal information as described in our Privacy Policy. These
rights are subject to certain exceptions and limitations. To exercise your
rights, please complete this form and we will respond as required by
applicable law and within the timeframe required by law.

We will use the information you provide to process your request. For requests
other than opt-outs, we may ask for additional information or documents to
verify your identity or to verify that you have authorized an agent to submit
a request on your behalf. The information you provide will be used only
to respond to your request.

Requester Details

The California Consumer Privacy Act provides California residents with rights related to personal information as described in our Privacy Policy. These rights are subject to certain exceptions and limitations. To exercise your rights, please complete this form and we will respond as required by applicable law and within the timeframe required by law.

We will use the information you provide to process your request. For requests other than opt-outs, we may ask for additional information or documents to verify your identity or to verify that you have authorized an agent to submit a request on your behalf. The information you provide will be used only to respond to your request.

Requester Details

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Name*

First Name Last Name

State or Providence of Residence*

Phone Number

Email Address (required if submitting request to delete)*

Authorized Agent Name (if applicable)

Authorized Agent Email Address (if applicable)

Request Type(s)*

Please visit our Privacy Policy for information about these types of privacy requests.

Requests to know:

Request a copy of the categories of personal information we collect, use, disclose, and sell about you.

Request a copy of the specific pieces of personal information we collect, use, disclose, and sell about you.

Request a copy of the categories of sources from which we collected personal information about you; our purposes for collecting or selling personal information about you; the categories of personal information about you that we have sold or disclosed for a business purpose; and the categories of third parties with which we have shared personal information.

Request to correct inaccuracies in the personal information we have collected about you.

Request to delete the personal information we have collected about you.

Requests to opt out:

Request to opt out of the sharing or processing of personal information for targeted advertising.

Request to opt out of the sale of personal information.

Please note that if you opt out of certain practices, we may be unable to provide
you with some services. You will not receive discriminatory treatment for the
exercise of the above privacy rights.

Additional Details

Please provide any additional details you would like us to know about your request.
If you are an agent submitting this request on someone else’s behalf, please
describe your authorization here. If you are submitting a request to correct
information, please explain what information you would like to be corrected.

Please note that if you opt out of certain practices, we may be unable to provide you with some services. You will not receive discriminatory treatment for the exercise of the above privacy rights.

Additional Details

Please provide any additional details you would like us to know about your request. If you are an agent submitting this request on someone else’s behalf, please describe your authorization here. If you are submitting a request to correct information, please explain what information you would like to be corrected.

Millicent Pharma Privacy Request Form

Requester Details

Requester Details

Request Type(s)*

Additional Details

Additional Details