GLBA Privacy Notice Acknowledgment Form

Customer acknowledgment form for initial privacy notice delivery and consent-related recordkeeping under the Gramm-Leach-Bliley Act (GLBA) for credit and lease applicants.

Notice and Submission Details

• Privacy Notice Version
  Enter the version identifier or effective date of the privacy notice provided to the applicant.
• How was the privacy notice delivered?
• If other, describe the delivery method
• Application Type
• Application Reference Number
  Optional internal reference number for linking this acknowledgment to the applicant file.

Applicant Acknowledgment

• I acknowledge that I received the initial GLBA privacy notice.
• Applicant Name
  Enter the name of the applicant signing this acknowledgment.
• Applicant Email
  Optional contact email for sending a copy of the acknowledgment or notice.
• Acknowledgment Date
  Select the date the applicant acknowledged receipt of the notice.
• Applicant Signature
  Electronic signature confirming receipt of the privacy notice.

Alternate Delivery or Exception Handling

• Reason the applicant could not sign electronically
• Exception Notes
  Document any alternate acknowledgment method, including paper form reference or staff-assisted delivery. Avoid unnecessary PII.
• Staff Member Name
  Optional staff name for the audit trail if staff assisted with delivery or collection.

Consent, Disclosure, and Submission

• I understand this form collects limited PII for compliance recordkeeping and audit trail purposes.
• Submission Disclosure