California Consumer Privacy Act Request Form NameThis field is for validation purposes and should be left unchanged.Request for Personal InformationBy filling out this form, you are requesting Park National Bank to provide you with details of any personal information that we or our affiliates have collected from or about you. If you have a customer relationship with us, we will respond to your request using the contact information that we have on file for you. If you are not our customer we will respond to your request using the address you provide below. Note: Proper authentication is required to ensure protection of personal information. You may be required to provide proof of identify before Park will respond to your request. We will respond to your request consistent with applicable laws.Personal Details:Name(Required) First Middle (optional) Last Suffix Birth Date(Required) MM slash DD slash YYYY Last 4 digits of you social security number(Required)Please enter a number less than or equal to 9999.Contact Info:Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone(Required)Are you a California Resident?(Required) Yes No – you are unable to submit this request 2. Are you submitting this request as an authorized agent* for another California resident?(Required) Yes No *For verified consumer requests, you must be a person registered with the California Secretary of State authorized to act on behalf of the consumer, or a parent or legal guardian of a minor child to submit a CCPA request. You will be required to provide supporting documentation. Request and supporting documents that cannot be verified will not be processed. Supporting documentation may include written authorization signed by the consumer, a valid power of attorney, guardianship documentation, or other legally sufficient evidence of authority. Scope Air may require additional verification before processing the request.What is your relationship with Park National Bank?(Required) Current customer/client or other account holder Former customer/client or previously applied for an account Never had an account Website visitor Other What type of request would you like to make? Select all that apply.(Required) Request to Know Categories of Personal Information Collected Request to Know Specific Personal Information Collected Request to Delete Personal Information Request to Correct Inaccurate Personal Information If requesting correction, identify the information you believe is inaccurate and provide the requested correction:Verification NoticeTo protect your privacy and security, Park may require additional information to verify your identity and process your request. Failure to provide sufficient verification information may delay or prevent completion of your request. Park will take reasonable steps to verify the identity of the requesting individual and, where applicable, the authority of any authorized agent. We may request additional information if necessary to verify identity or process the request. Failure to provide sufficient verification information may prevent us from fulfilling the request.AcknowledgementBy submitting, I certify that the information provided is accurate and complete to the best of my knowledge and that I am the consumer identified in this form or am authorized to act on the consumer’s behalf. Certain information maintained by Park National Bank may be exempt from rights otherwise available under California privacy laws because the information is governed by federal financial privacy laws, including the Gramm-Leach-Bliley Act and related regulations. Each request will be reviewed and processed in accordance with applicable law.
