Subject Access Request Form

I, the undersigned Data Subject, do hereby swear, certify, and attest the following:

  1. I am a citizen and/or resident of __________________________, which is located within the European Economic Area;

  2. I own and operate one or more mobile devices with the following mobile advertising identifier(s) (please attach screen shot):
    _________________________________________________; _________________________________________________;

  3. I own and operate a device on which is stored at least one cookie set by the domain, which contains the following string(s) of text (please attach screen shot): _________________________________________________; _________________________________________________;

  4. The following email address(es) are directed to an email inbox which I own, license or otherwise control:
    _________________________________________________; _________________________________________________;

  5. The following telephone number(s) are directed to a phone which I and/or my family owns, licenses or otherwise controls:
    _________________________________________________; _________________________________________________;

  6. I have the authority under applicable laws, rules, and regulations, to submit a subject access request for personal data outlined above; and

  7. I am not requesting this information for any fraudulent, criminal, malicious, or otherwise unlawful purpose. I declare under penalty of perjury that the foregoing is true and correct. If I seek personal data that is not my own or I am not authorized to make this request, I indemnify Vertical Mass and its affiliates against any claims brought by the rightful subject of the personal data.

Data Subject: ______________________________________________

Signature: _________________________________________________

Full Name: _________________________________________________

Date: ______________________________________________________