| Category of Personal Information | Is information collected by us? | Is information transferred for business purposes? |
| Audio, electronic, visual, thermal, olfactory, or similar information | ☐ | ☐ |
| Bank account number | ☐ | ☐ |
| Biometric information | ☐ | ☐ |
| Characteristics of protected classifications (e.g., age, sex, race, ethnicity, physical or mental handicap, etc.) | ☐ | ☐ |
| Commercial information (e.g., products or services purchased, or other purchasing or consuming histories or tendencies) | ||
| Credit card number | ||
| Debit card number | ||
| Driver’s License Number / State ID | ☐ | ☐ |
| Education | ☐ | ☐ |
| Electronic network activity (e.g., browsing history) | ||
| Email address | ||
| Employment | ||
| Employment history | ☐ | ☐ |
| Geolocation data | ||
| Health insurance information | ☐ | ☐ |
| Identifiers (e.g., name or alias) | ||
| Insurance Policy Number | ☐ | ☐ |
| Medical information (not covered by HIPAA) | ☐ | ☐ |
| Online identifier (e.g. IP address) | ||
| Other financial information | ☐ | ☐ |
| Passport Number | ☐ | ☐ |
| Physical Characteristics | ☐ | ☐ |
| Postal address | ||
| Signature | ||
| Social Security Number | ☐ | ☐ |
| Telephone Number | ||
| Transaction information |
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