Full Legal Name:
Date of Request:	CalendarToday
Authorized Agent's Full Legal Name:	If you are not the Consumer making the request but rather an authorized agent of the Consumer, please state your full name: (References to “you” or “your” mean Consumer, not the Consumer’s authorized agent.)
Are you a resident of the State of California?:	Yes No If you marked “No” above, you do not have any rights under the CCPA and we will therefore not respond to this submission.
Are you a member of Premier America Credit Union?:	Yes No
Member Number:	If you marked “yes” above, please provide your membership number.
Do you have Online Banking with us?:	Yes No
Online Access:	Yes No If you marked “yes” above, have you shared your username and password with anyone else?
Employee Status:	Yes No Are you our past or current employee of Premier America Credit Union?
Member's Email Address:
Member's Phone Number:	( ) - Second three digits Last four digits
Member's Mailing Address:
Authorized Agent's Email Address (if applicable) :
Authorized Agent's Phone Number (if applicable) :	( ) - Second three digits Last four digits
Authorized Agent's Mailing Address (if applicable) :	*You authorize us to contact the Consumer and/or the Consumer’s authorized agent (if applicable) for identity verification purposes in accordance with our legal obligations.
1) Request to Know (please check all that apply to your request):	The specific pieces of personal information we collected about you in a form that you can take with you (also called a “data portability request”). The categories of personal information we collected about you. The categories of sources for the personal information we collected about you. Our business or commercial purpose for collecting, sharing or selling that personal information. The categories of third parties to whom we disclosed, shared or sold your personal information.
2) Request to Delete Personal Information? :	Yes No
3) Request to Correct Personal Information:	Yes No
If "yes" to question 3, Please briefly describe what information needs to be corrected: :
If for any reason we are unable to correct, would you like us to consider deleting the information instead?:	Yes No
Confirmation of Identity:	I, [Insert Your Name Here], declare, under penalty of perjury under the laws of the State of California, that I am submitting this request in my capacity as the member or authorized agent on behalf of the member.
Signature:

We will need to verify your identity. Within 10 business days of your submission of this form, we will notify you of what we will need to verify your identity. If you are an authorized agent for the above referenced consumer, we will request a copy of your government issued identification card, and written authorization from the consumer to submit the request. Additional details will be provided to you regarding what we need to verify you and your request within 10 business days of your submission of this form.

Please submit any documents that you would like us to consider in support of your request for us to correct the contested personal information to marketing.requests@premieramerica.com.  We may require additional documentation from you regarding the contested personal information. We may deny your request if we determine that the contested personal information is more likely than not accurate based on the totality of circumstances.