Data Subject Application Form

In order for you to submit your requests under Article 11 of Law No. 6698 on the Protection of Personal Data, for us to contact you, and to verify your identity, we kindly ask you to fill in the fields below completely and attach any relevant information and documents (if available):

1. Contact Information of the Applicant

Full Name:
Turkish ID Number (For foreigners: Nationality and Passport Number or ID Number):
Notification Email or Registered Electronic Mail (KEP) Address:
Phone and/or Fax Number:
Residential or Workplace Address for Notification:

2. Your Relationship with Our Company

Relationship	Mark with (X)	(If any, please provide explanation)
Patient
Employee
Former Employee
Supplier
Business Partner
Visitor
Other

3. Application Methods

#	Application Method	Application Address	Application Procedure
1. Written Application	By hand with wet signature, by proxy, or via notary	Aksoy Mah. Girne Bul. No: 38E Karşıyaka / İzmir – Turkey	The envelope/petition should include the phrase "Request for Information under the Law on the Protection of Personal Data" or a similar phrase.
2. Electronic Notification	Via Electronic Notification	Electronic Notification Address: 25868-70766-96477	The subject line of the email should include "Request for Information under the Law on the Protection of Personal Data" or a similar phrase.
3. Application via registered or non-registered email address in our system	Using your email address, whether registered in our system or not	dentafix.clinics@gmail.com	The subject line of the email should include "Request for Information under the Law on the Protection of Personal Data" or a similar phrase.

4. Your Request

Please specify your request under Law No. 6698 on the Protection of Personal Data in detail below. (*) If your explanations do not fit in the space below, please use the additional page provided.

5. Method of Delivering/Notifying Our Response to You

Please select one or more of the following methods to receive the response from our company:

Option	Mark with (X)
I request that the response be delivered/notified via the "Residential or Workplace Address for Notification" I provided above.
I request that the response be delivered/notified via the "Notification Email Address" I provided above.
I request that the response be delivered/notified via the "Registered Electronic Mail (KEP) Address" I provided above.
I request that the response be delivered/notified via the "Fax Number" I provided above.

I confirm that the information provided in this Data Subject Application Form is accurate and up-to-date.

Applicant (Data Subject)

Full Name:

Signature:

Date:

Attachments: Relevant Information and Documents (if any, please list numerically)

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