SECTION 1: Details Of The Individual Requesting Deletion

First Name* Last Name*
* *
Street*
 
City* State*
 
Postal Code* Country*

SECTION 2: Are You The Data Subject?

Are You The Data Subject?*

To ensure that we are erasing data of the correct individual, we require that you provide us with proof of identity, as well as proof of address.

Using the File Upload sections below, please supply us with a photocopy or scanned image (DO NOT SEND ORIGINALS) of one or both of the following:

1) Proof Of Identity
--Passport / Photo Driver's License / National Identity Card / Birth Certificate

2) Proof Of Address (optional)
--Utility Bill / Bank Statement / Credit Card Statement (no more than 3 months old) / Current Driver's License

If we are not satisfied with your proof of identity & address, we reserve the right to refuse your request for permanent deletion.

Proof Of Identity (Attach File)*
Proof Of Address (Attach File - optional)

SECTION 3: Details Of The Data Subject (If different from Section 1)

First Name Last Name
Street
 
City State
 
Postal Code Country

SECTION 4: Reason For Erasure Request

Given the sensitive nature of erasing personal data, GDPR Article 17(1) requires certain conditions to be met before a request may be considered.

Please check the box below with the reason you wish your data to be erased and please use the File Upload below to attach any justifying documents to this form that you feel should accompany your request (this is purely optional).

Please Check The Appropriate Box*
Justifying Documentation For Erasure (optional)

SECTION 5: What Information Would You Like To Be Permanently Erased?

Please use the box below to describe the information you wish to be erased. Please provide any relevant details you think will help us to identify the information. Providing specific URLs for each link or page where information may have been collected that you wish to be removed would be helpful.

Also, please explain, if it is not abundantly clear, why the linked page is mentioned and if it is about you or the person you are representing on this form.

Please note that: In certain circumstances, where erasure would adversely affect the freedom of expression, contradict a legal obligation, act against the public interest in the area of public health, act against the public interest in the area of scientific or historical research, or prohibit the establishment of a legal defense or exercise of other legal claims, we may not be able to erase the information you requested in accordance with article 17(3) of the GDPR. In such cases you will be informed promptly and given full reasons for that decision.

While in most cases we will be happy to erase the personal data you request, we nevertheless reserve the right, in accordance with Article 12(5) of the GDPR, to charge a fee or refuse the request if it is considered to be “manifestly unfounded or excessive.” However we will make every effort to provide you with the erasure of your personal data if suitable.

Information You Would Like Erased*

SECTION 6: Declaration

Please copy, print and sign & date the Declaration Statement below.

You will then need to upload a photocopy or scanned image of that very signed/dated Declaration Statement using the File Upload below.


DECLARATION STATEMENT TO INCLUDE:

I confirm that I have read and understood the terms of this subject access form and certify that the information given in this application to NeoCertified is true. I understand that it is necessary for NeoCertified to confirm my (the data subject’s) identity and it may be necessary to obtain more detailed information in order to locate the correct personal data.

Signed: __________________        |       Date: __________________

 



Please note that any attempt to mislead may result in prosecution.

Declaration Statement (Signed & Dated)*

Documents which must accompany this form submission:

  • Evidence of your identity (see section 2)
  • Evidence of the data subject’s identity (if different from above)
  • Authorization from the data subject to act on their behalf (if applicable)
  • Justification for erasure of data (see section 4)