I am submitting a request for: *

Authorized Agent Affidavit

A completed and signed affidavit is required in order for Samaritan's Purse to fulfill this request. Once you submit this request and have been verified by Samaritan's Purse, you will receive an email with a subject of “Data Subject Request Started”. Please open that email, and click on the “View or manage your request” button to log into the Data Privacy Center. Here, you will be able to upload the affidavit, which can be found at the link below.

Please provide the following information to start your request:

* Required fields

What is your relationship with Samaritan's Purse? Select all that apply. *

Donor

Employee / job or DART applicant

Church partner

Vendor / contractor

Volunteer

Other

What is the reason for contacting us? Select all that apply. *

Please specify what needs to be updated/corrected *

First Name *

Last Name *

Previous Names or Nicknames

Phone Number

Email*

Address *

City *

Zip Code *

State *

Authorized Agent Email for correspondence *

Authorized Agent First and Last Name *

Authorized Agent Relationship with Data Subject *

What is the Data Subject's relationship with Samaritan’s Purse? Select all that apply. *

Donor

Employee / job or DART applicant

Church partner

Vendor / contractor

Volunteer

Other

What is the reason for contacting us? Select all that apply. *

Please specify what needs to be updated/corrected *

Data Subject Information

First Name *

Last Name *

Previous Names or Nicknames

Phone Number

Email*

Address *

City *

Zip Code *

State *

Submit a Data Privacy Request

Confirmation

Authorized Agent Affidavit

Data Subject Information