Nevada Privacy Form

First Name:*

Last Name:*

Email Address:*

Date of Birth:* (MM/DD/YYYY format)

Last 4 Digits of Your Social Security Number:* (e.g. 0124)

Please list all educational institutions you have attended:*

By providing us with the information above, you are certifying that you are a Nevada resident as defined by state law. While the Clearinghouse does not exchange, for monetary consideration, the data individuals provide to us, we are nevertheless required to provide you with this opt-out right.