I hereby attest that all information stated in this form are all true and correct to the best of my knowledge. Any concealment, false statement, and/or non-declaration shall constitute fraud, which shall be ground to file a legal action against me; I therefore waive my rights to institute any case arising from this situation.

Likewise, I hereby attest that I been informed of the purpose for the processing of the Information that I provided, and that I expressly give my consent therefor.

Furthermore, as an Attorney-in-Fact / Authorized Representative of the Data Subject (if applicable in this request), I warrant that I have: (i) obtained authorization from the Data Subject to disclose their information included in this form; and that (ii) the Data Subject has been informed of the purpose for the disclosure and collection of information.

I agree to indemnify and hold the Company free and harmless from any and all claims arising from the breach of this warranty, for damages, and for actual legal fees to defend such claims, if any.

This consent for the Company to use or process the information herein shall be valid for the purpose of the request herein.

By using this form, I confirm that I have read, understood and accept the Privacy Policy and consent to being contacted in connection with this matter.