Authorized Agent Designation Form
Instructions: If you are a resident of California and would like to designate an authorized agent to submit a request on your behalf related to your personal information, please print this page and complete this form in its entirety. A signed and notarized copy of this form must be submitted to us at the appropriate address below. Please note, if Vince, LLC is unable to verify the identity of the individual submitting this form (the “Requestor”), we may ask for additional information or documents for verification purposes. For more information, please see our Privacy Policy.
If sending by mail, please use the following address:
500 Fifth Ave, 20th Floor
New York, NY 10110
If sending by email, please use the following address:
1. Requestor Information
Full Name
Mailing Address
Email Address
Phone Number
2. Authorized Agent Information
Full Name of Authorized Agent
Email Address of Authorized Agent
Phone Number
Authorized Agent’s California Secretary of State Registration Number[1] (if applicable)
3. Authorization
I, Requestor, designate the Authorized Agent listed above for the sole purpose of submitting the following request(s) on my behalf (check all that apply):
☐ Request to delete my personal information; and/or
☐ Request to access my personal information.
By signing below and submitting this Authorized Agent Designation form, I affirm the following:
- I am a California resident.
- I am the Requestor whose name appears above and the information provided in this form is true and accurate.
- The Authorized Agent is a natural person or a business registered with the Secretary of State to conduct business in California.
- I understand that I may be contacted directly in order to verify my identity and confirm designation of my Authorized Agent.
- I grant the Authorized Agent permission to submit the request(s) indicated above to Vince, LLC on my behalf.
- I authorize Vince, LLC to process such request(s) and I understand that any responses produced in connection with a request to access my personal information will not be sent to my Authorized Agent, but will instead be sent directly to me at the address provided above.
- The authority granted by this form will terminate 90 days after the date of execution.
- I agree to indemnify Vince, LLC for any and all claims that arise against Vince, LLC in relation to its reliance on this Authorized Agent Designation form.
Signature of Requestor
Today’s date (mm/dd/yyyy)
4. Notary Information
State of _____________
County of _____________
I, __________________________________, do hereby confirm that on this ______ day of ________, 20_____, the person named____________________________________________, appeared before me and has proven to be the individual named in Section 2 of the preceding document, and has acknowledged to me that this authorization is his/her wish.
Signature of notary public
Notary seal (if state requires a seal)
* The notary seal must be dated within 30 days of receipt of this document by <<COMPANY>>.
Commission expiration date (mm/dd/yyyy)
[1] Please note, if you are designating an entity to act on your behalf, California law requires that such entity is registered with the Secretary of State.