Consumer Authorization Form
Client or authorized representative granting authorization
*
First Name
Last Name
Client or authorized representative email
*
example@example.com
Date that authorization given
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Assisting Agent
First Name
Last Name
I give permission to ACME and their licensed agents to maintain, store, and/or use my PPI in order to carry out the roles and responsibilities of a licensed sales agent. I understand that they might need to create, collect, disclose, access, maintain, store, and/or use some of my PII in order to provide assistance. I may revoke this authorization at any time by notifying ACME or my agent.
Yes
No
Signature
*
Submit
Submit
Should be Empty: