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This Authorized Agent Designation form may be used by individuals who are residents in the State of California (“California Consumers”) whose Personal Information is collected by Pacific Homecare Services (the “Company”) to designate an Authorized Agent for purposes of the California Privacy Rights Act (“CPRA””).
By signing and submitting this form, you are designating the person or entity identified in Section III, below, as your Authorized Agent. Once designated, your Authorized Agent will have the authority to submit a request, on your behalf, to exercise the “right to know”, the “right to correct”, and the “right to delete” as provided in the CPRA. For more information about these rights, please review the Company’s Notice at Collection and Privacy Policy for HR Individuals Who Reside in California, which is available here.
The completed and signed form must be submitted to the Company via email to hr@pacifichomecare.com. The Company may take steps to verify your or the Authorized Agent’s identity in response to (a) your submission of this form, or (b) a request submitted by your Authorized Agent. If you provide the Authorized Agent with a power of attorney that complies with California law, the Company will not require additional verification.
Authorized Agent's Name
Authorized Agent's Mailing Address
Authorized Agent's Phone Number
Authorized Agent's Email Address
Authorized Agent's Date of Birth (for verification purposes) unless the Authorized Agent is a business entity
You may terminate or change the authorization at any time. Your termination of, authorization, or changes to, the authorization, must be submitted to the Company by email to hr@pacifichomecare.com. Any request to terminate or change the authorization may take up to thirty (30) days from the Company’s receipt of your request. Any termination or change in authorization will have no effect on actions taken by the Company before receiving the request to terminate or change the authorization
By signing below, I hereby designate the Authorized Agent listed in Section III, above, to exercise on my behalf the rights described above.
Printed Name
Signature
Date
