JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Opt Out Form
Please provide the following information to opt out from GoodSegments
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Who is opting out?
Me
A person for whom I am parent, legal guardian or legal power of attorney
A person that has died who was a member of my family
Authorized Agent on behalf of a California Resident
3rd party or Authorized Agent on behalf of a Non-California Resident
Clear selection
Title
*
Mr.
Mrs.
Ms.
Dr.
Honorable
Reverend
Other:
First Name
*
Your answer
Middle Name
*
Your answer
Last Name
*
Your answer
Suffix
*
None
Sr.
Jr.
I
II
III
IV
Other:
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of GoodSegments.
Does this form look suspicious?
Report
Forms
