Ethos Intelligence Form Name(Required) First Middle Last Alias Names Date of Birth(Required) MM slash DD slash YYYY Current Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Previous Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Consent(Required) I hereby authorize Ethos Intelligence to act as my agent and give Ethos Intelligence the right to fulfill necessary obligations on my behalf in all manners relating to data removal. I hereby authorize Ethos Intelligence to keep, maintain and use my data for the duration of our Engagement in all manners relating to data removal.