CCPA Request Form
(Last Updated: May 25th, 2023)
To help facilitate our processing of your request, please fill out, attach and send your request to [email protected] or mail it to
550 Hills Drive, Ste 200B
Bedminster, NJ 07921
ATTN: Website Team
Any documentation supporting the basis of your authorization, e.g., as applicable, your registration with the California Secretary of State, a power of attorney pursuant to Probate Code sections 4121-4130, and/or signed permission that the person has authorized you to make a request on their behalf. We also may ask this person to confirm that they have given you authorization to submit the request on their behalf.
Answer the remaining questions on behalf of the person for whom you are authorized to make the request.
1. Are you making the request on your own behalf?
[ ] Yes – I am making this request on my own behalf. Please skip to question 3.
[ ] No – I am making this request on another person’s behalf. Please proceed to question 2.
2. If you are making a request on another person’s behalf, please do the following:
Provide your own contact details:
- Full Name:
- Mailing Address:
- Telephone Number:
- Email Address:
· Explain your relationship to that person: _________________.
· Detail the basis of your authorization to make the request on that person’s behalf: ___________________
3. Are you a resident of California?
[ ] Yes
[ ] No
4. What is your relationship to Biocodex?
[ ] I am a website visitor
[ ] I am a customer
[ ] I am Biocodex employee, consultant or job applicant
[ ] Other (please describe): _______________
5. What would you like to do?
[ ] I would like to unsubscribe from Biocodex’s mailing list.
[ ] I would like to know what kinds of personal information Biocodex has collected, used, and shared about me in the past 12 months.
[ ] I would like Biocodex to provide me with copies of the personal information that Biocodex has collected about me in the past 12 months.
[ ] I would like Biocodex to delete the personal information it collected from me.
[ ] I would like Biocodex to correct the inaccurate personal information it maintains about me
6. Have you made any similar requests to Biocodex in the last 12 months?
[ ] Yes– if yes, please briefly identify the nature and approximate date of any such request here: ______________.
[ ] No
7. Please provide the following information to help us respond to your request:
· Full Name:
· Mailing Address:
· Telephone Number:
· Email Address:
8. Please let us know if there are any other details you’d like to share with us about your request.
· If you are making a request for correction, please explain what information you believe is inaccurate: ______.
· If you are making a request for disclosures or copies, please feel free to describe the relevant time periods, specific documents, or business area you are interested in: ______.
We may ask for additional information in order to verify and validate your request.