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Data Subject Access Request Form
Article 15 of the EU General Data Protection Regulation (Regulation (EU) 2016/679) (GDPR) grants you the right to access your personal data held by Medochemie Ltd, including the right to obtain confirmation that we process your personal data, receive certain information about the processing of your personal data, and obtain a copy of the personal data we process. We require that you submit this request in writing via email to dpo@medochemie.com.
We expect to respond to your request within one month of receipt of a fully completed form and proof of identity.
In addition to exercising your right to access your personal data, the GDPR also grants you the right to:
•	Request correction or erasure of your personal data.
•	Restrict or object to certain types of data processing.
•	Make a complaint with the local data protection authority.
For more information on your rights under the GDPR, please see Medochemie’s Data Subject Rights Policy and Privacy & Cookie Policy available at: www.medochemie.com. 
I. Requester Name (Data Subject) and Contact Information
Please provide the data subject’s information in the space provided below. (If you are making this request on the data subject’s behalf, you should provide your name and contact information in Section III.)
We will only use the information you provide on this form to identify you and the personal data you are requesting access to, and to respond to your request.
First and last name:

Any other names that you have been known by (including nicknames):

	
Home address:

Date of birth:

Telephone number:

Email address:

If you are a current or former employee of Medochemie Ltd, please provide your employee identification number (if available) and your approximate dates of employment:

Please provide other unique identifiers or related information to help us locate your personal data (for example, government identification number or customer account number):

II. Proof of Data Subject’s Identity
We require proof of your identity before we can respond to your access request. To help us establish your identity, you must provide identification that clearly shows your name, date of birth, and current address. We accept a photocopy or a scanned image of one of the following as proof of identity: passport or national identification number card. If you have changed your name, please provide the relevant documents evidencing the change.
If you do not have any of these forms of identification available, please contact Mrs. Giota Andreou at 00357 25 852696 or dpo@medochemie.com for advice on other acceptable forms of identification. 
We may request additional information from you to help confirm your identity and your right to access, and to provide you with the personal data we hold about you.
​                                                                                                                                       III. Requests Made on a Data Subject’s Behalf
Please complete this section of the form with your name and contact details if you are acting on the data subject’s behalf.
First and last name:

Home address:

Date of birth:

Telephone number:

Email address:

We accept a photocopy or a scanned image of one of the following as proof of your identity: passport or national identification number card. If you do not have any of these forms of identification available, please contact Ms. Giota Andreou at 00357 25 852696 or dpo@medochemie.com for advice on other acceptable forms of identification. We may request additional information from you to help confirm your identity if necessary.
We also require proof of the data subject’s identity before we can respond to the request. To help us establish the data subject’s identity, you must provide identification that clearly shows the data subject’s name, date of birth, and current address. We accept a photocopy or a scanned image of one of the following as proof of identity: passport or photo identification such as passport or national identification number card. If the data subject has changed his/her name, please provide the relevant documents evidencing the change.
We accept a copy of the following as proof of your legal authority to act on the data subject’s behalf: a written and notarized consent signed by the data subject, a certified copy of a Power of Attorney, or evidence of parental responsibility.
We may request additional information from you to help confirm the data subject’s identity. We reserve the right to refuse to act on your request if we are unable to verify your legal authority to act on the data subject’s behalf.
​                                                                                                                                       IV. Information Requested
To help us process your request quickly and efficiently, please provide as much detail as possible about the personal data you are requesting access to. Please include time frames, dates, names, types of documents, file numbers, or any other information to help us locate your personal data.
We will contact you for additional information if the scope of your request is unclear or does not provide sufficient information for us to conduct a search (for example, if you request “all information about me”). We will begin processing your access request as soon as we have verified your identity and have all of the information we need to locate your personal data.
In response to your request, we will provide you with the information required by Article 15 of the GDPR.
If the information you request reveals personal data about a third party, we will either seek that individual’s consent before responding to your request, or we will redact third parties’ personal data before responding. If we are unable to provide you with access to your personal data because disclosure would violate the rights and freedoms of third parties, we will notify you of this decision.
Applicable law may allow or require us to refuse to provide you with access to some or all of the personal data that we hold about you, or we may have destroyed, erased, or made your personal data anonymous or pseudonymous in accordance with our record retention obligations and practices. If we cannot provide you with access to your personal data, we will inform you of the reasons why, subject to any legal or regulatory restrictions.
Description of your request:

		

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V. Signature and Acknowledgment
I, ___________________________, confirm that the information provided on this form is correct and that I am the person whose name appears on this form. I understand that: (1) Medochemie Ltd must confirm proof of identity and may need to contact me again for further information; (2) my request will not be valid until Medochemie Ltd receives all of the required information to process the request; and (3) I am entitled to one free copy of the personal data I have requested, and acknowledge that for any further copies I request, Medochemie Ltd may charge a reasonable fee based on administrative costs.
If you would like to receive a copy of the personal data you are requesting access to, please indicate below whether you would like a hard copy or an electronic copy:
____ Hard copy.
____ Electronic copy.
__________________________________
Signature
__________________________________
Date
VI. Authorized Person Signature
I, _____________________________, confirm that I am authorized to act on behalf of the data subject. I understand that Medochemie Ltd must confirm my identity and my legal authority to act on the data subject’s behalf, and may need to request additional verifying information. I understand that: (1) Medochemie Ltd must confirm proof of identity and may need to contact me again for further information; (2) my request will not be valid until Medochemie Ltd receives all of the required information to process the request; and (3) I am entitled to one free copy of the personal data I have requested, and acknowledge that for any further copies I request, Medochemie Ltd may charge a reasonable fee based on administrative costs. If you would like to receive a copy of the personal data you are requesting access to, please indicate below whether you would like a hard copy or an electronic copy:
____ Hard copy.
____ Electronic copy.
__________________________________
Signature
__________________________________Date