Untitled Document

Name *:

Address 1:

Address 2:

City:

State:

Zip:

Email *:

Phone *:

Requestor Type: I am a

Type of Request:

If you are exercising a Right to Know Request, what are you requesting?

Please provide the below information about the consumer who is making the request (or if you are an agent, on behalf of whom you are making this request) so that we may use the information to verify the consumer’s identity.

Consumer's Name *:

Consumer's Address 1:

Consumer's Address 2:

Consumer's City:

Consumer's State:

Consumer's Zip:

Consumer's Email *:

Consumer's Phone *:

Loop Loyalty Account Number: