Consumer Rights Request Form

In accordance with applicable U.S. privacy law, and depending on the jurisdiction in which you reside, you may be able to exercise certain data rights regarding your personal information. Please complete this form to submit your request by emailing us at privacy@dompe.com.

You may also submit your request by contacting us over the phone at 1 (800) 868-2185.

For more information about these rights, please see our Privacy Policy.

In some cases, we may require additional information if we are unable to verify your request based on the information you have provided. The personal information submitted in connection with this request will be used to process your request.

To manage your cookie preferences, please visit the Cookie paragraph in Section 1.2 of our Privacy Policy .

Fields marked with an asterisk (*) must be completed in order to submit this form. Complete the fields below using the consumer’s information.

First & Last Name *

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Company Name

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Job Title

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Email *

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Phone Number

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Date *

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Street / Address *

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Apartment / Suite

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Please identify your relationship with us: *

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Notes

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Right to Access / Portability (Right to obtain access to the personal information we have collected about you and, where required by law, the right to obtain a copy of the personal information).

Right to Know (Right to know the categories of personal information we have collected about you in the past 12 months).

Right to Correction (Right to request that any inaccuracies in your personal information be corrected, taking into account the nature of the personal information and the purposes of the processing of your personal information).

Right to Deletion (Right to request the deletion of personal information we have collected from you, subject to certain exceptions).

Right to Opt Out of Targeted Advertising (You may also have the right to opt out of the use of your personal information for targeted advertising purposes. In California, this is also referred to as the right to opt-out of sharing your personal information for cross-contextual advertising purposes. Please also visit our the Cookie paragraph in Section 1.2 of our Privacy Policy to manage your cookie preferences. Please note this opt out is browser-specific. You must reset your preferences if you clear cookies or use a different browser or device).

By submitting this request via email to privacy@dompe.com, I am confirming the following:

1. Accuracy: The information I have provided is true and accurate;

2. Privacy: I understand the information will be processed by Dompé U.S. Inc. in accordance with its Privacy Policy ;

3. Contact: I authorize Dompé U.S. Inc. and or its affiliates and or agent(s) to contact me (and or the Authorized Agent identified in these documents) to verify my identity and to process this request.

Authorized Agents only:

If you’re an Authorized Agent submitting a request on behalf of a consumer, you must submit an email to privacy@dompe.com and attach written authorization from the consumer indicating you’ve been authorized to submit a request on the consumer’s behalf. The form must be signed by both you and the consumer. All forms not signed will be rejected.

Note that you also have the right to appeal in the event that we decline to take action on a request exercising one of your rights set forth above, you have the right to appeal our decision.