*Are you making this request for yourself or for someone else (i.e., as an Authorized Agent)?

Myself For someone else

Please note that you are submitting this request as an authorized agent (e.g., a parent representing their child, a lawyer representing their client, a spouse, a legal guardian, etc.) for the individual, and you will be required to provide GSK with written proof, once GSK sends you an acknowledgement, that the individual has asked you to make this request on their behalf, unless the individual chooses to verify themselves directly with GSK.

Authorized Agent Personal Information

First Name *

Middle Name or Initial

Last Name *

Business Name (if applicable)

Relationship to the Individual *

Email *

Please ensure you have entered your email address correctly, in case we need additional information to process your request.

Requester Personal Information

To ensure we are able to initiate your request, please complete your (or the individual's) specific information below.

Title

First Name *

Middle Name / Initial

Last Name *

Address Type *

Please enter your permanent mailing address

Address 1 *

Address 2

City *

State *

Zip *

Email *

Enter "N/A" if the Requester does not have an email address.

In what capacity are you making this request? * Patient (An individual who has taken, or presently takes, a GSK prescription medicine or vaccine.) Consumer (An individual who has used, or presently uses, a GSK over-the-counter product or service.) Research subject Healthcare professional Supplier/Vendor Other

Select those values that apply to your request.

Request Details

To ensure we are able to fulfil your request, please indicate which individual rights are being exercised below.

Please select the individual right(s) you would like to exercise * Right to access

I would like to know what personal information GSK collects and holds on me

Right to delete

I would like to have all of my personal information deleted

*Preferred Contact Method?*

If we need additional information to process your request, how would you like to be contacted?

Please ensure you have entered your email address correctly.

Mailing Address

Please ensure you have entered a valid mailing address correctly in the section above.

CCPA Individual Privacy Rights Request Self-Service Form

Authorized Agent Personal Information

Requester Personal Information

Request Details