Accountable Healthcare Staffing, Inc. California Consumer Privacy Act Request Form

Under the California Consumer Privacy Act and the California Privacy Rights Act (hereinafter “CCPA”), residents of the State of California have the right to know about the Company’s collection and handling of their information, to correct any inaccurate personal information, to delete their personal information, and to opt-out of the sale and sharing of their personal information (“CCPA Rights”). Accountable’s California Privacy Policy explains that Accountable does not, and will not, sell personal information and provides a detailed explanation of the right to know, the right to correct, the right to delete, and the right to opt-out of the sale and sharing of personal information. California residents who wish to make a request to exercise a CCPA Right must complete the following form. An Accountable Team Member will contact you regarding your request within 10 days of receipt.

California residents can also make a request to exercise a CCPA Right by contacting 561.948.1619

Identifying Information:

Your Relationship With Accountable:

-- Choose relationship type --Talent Pool ProspectEnrolled ProviderEmployeeWebsite VisitorOther

Nature Of Request:

-- Choose request type --I would like to receive information about the categories of personal information the Company has collected about meI would like to receive information about specific pieces of personal information that the Company has collected about meI would like the Company to delete personal information that it has collected about meI would like the Company to correct any inaccurate personal information that it has collected about meI would like to opt-out of the sale of personal information that the Company has collected about meI would like to opt-out of the sharing of personal information that the Company has collected about meI would like to limit the use and disclosure of sensitive personal information about me

Please provide additional information about the specific pieces of personal information that are the subject of your request:

By typing your name herein, you are acknowledging that you are the listed individual or have authorization to request on behalf of the listed individual, and further verification may be required in order to process your request, such as providing a valid government issued picture identification, or a valid power of attorney pursuant to California law.