GLBA Privacy Notice Acknowledgment Form

Captures customer acknowledgment of the initial privacy notice provided under the Gramm-Leach-Bliley Act for credit and lease applicants.

Submission Notice

• Notice and acknowledgment statement
  By signing below, the applicant confirms receipt of the initial privacy notice required under the Gramm-Leach-Bliley Act (GLBA). This record will be retained for compliance purposes.
• What happens after I submit?
  Your acknowledgment will be saved to the compliance record and associated with the application file. If additional verification is needed, a compliance reviewer may follow up.

Applicant and Application Details

• Applicant full name
• Application type
• Application reference number
  Enter the internal application or account reference used for audit trail purposes.
• Application date

Privacy Notice Delivery

• How was the privacy notice delivered?
• Date notice was provided
• If other, describe the delivery method
• Privacy notice version or revision date
  Optional field for organizations that track notice versioning in their compliance program.

Acknowledgment and Signature

• I confirm that I received the initial privacy notice.
• Applicant signature
• Date signed

Compliance Audit Trail

• Recorded by
  Auto-filled by the system for audit trail purposes.
• Recorded at
  Auto-filled timestamp when the acknowledgment is saved.