Withdraw of Consent Form Withdraw of Consent Form, Article 7 UK GDPR 1 – Requestor Details This section includes details of the individual / company submitting this request. All fields marked as * are mandatory. Are you the Data Subject? * YesNo If you are the data subject, please enclose evidence of your identity with this form. Acceptable forms of identity are copies of either 1) driving licence; 2) passport; or 3) birth certificate 2 – Data Subject Details This section includes details of the individual whose personal data is requested. A separate form must be completed for each data subject All fields marked as * are mandatory. Title: Full Name: Current Address: Postcode: Telephone – Mobile Number: Email Address: Date of Birth: Previous Name(s) (if any): Previous Address (if at current address for less than 2 years): 3 – Details of the Request Case Reference ID Case Reference ID is the number that may have been provided to you in the email along with link to this form or other form of tracking personal data within the organisation. E.G. good practice in the register to establish an ID numbering system Please specify the processing types for which you would like to withdraw consent (Article 4[2] UK GDPR, "collection, recording, organisation, structuring, storage, adaptation or alteration, retrieval, consultation, use, disclosure by transmission, dissemination or otherwise making available, alignment or combination, restriction, erasure or destruction") Please provide any relevant information that will help us identify and specifically locate your personal data. any personal data provided to Ecogenica Ltd): 4 – Declaration (Mandatory) Upload proof of identification (passport, drivers’ licence, national id card or other) and any information of what personal data has been provided to Ecogenica Ltd. I am the data subject / authorised by the data subject named above and hereby request under the provisions of the GDPR that Ecogenica Ltd do not use my personal data for the specific processing mentioned in Section 3 of this form. I have enclosed all the required documents as stated in Section 1 above and hereby confirm that all the information supplied in this form is accurate to the best of my knowledge. *
