Authorized Agent Designation Form

Instructions: If you would like to designate an authorized agent to submit a request on your behalf, or if you are an authorized agent yourself, a signed and notarized1 copy of this form must be submitted to us along with your request.

Please note, if we are unable to verify the identity of the individual about whom information is being requested (the “Requestor”), we may ask for additional information or documents for verification purposes. For more information, please see our Privacy Policy available at https://health-ade.com/pages/privacysecurity.

If sending by mail, please use the following address:

Health-Ade Kombucha
Attention: Privacy Request
2012 Abalone Ave
Torrance, CA 90501

If sending by email, please use the following address:

help@healthade.com

1. Requestor Information
2. Authorized Agent Information
3. Authorization

Requestor, designate the Authorized Agent listed above for the sole purpose of submitting the following request(s) on my behalf (check all that apply):

1 Notarization is only required if this request is being submitted by a U.S. resident.
ACTIVE 706558542v1

4. Notary Information

If you are a resident of the United States, please complete the following notarization:

the person named as the Requestor in Section 1 above appeared before me, and has acknowledged to me that this authorization is his/her wish.