Alpmed Clinic

Personal Data Owner Application Form

Pursuant to Article 11 of the Law No. 6698 on the Protection of Personal Data (“KVKK”) and your rights set forth in Chapter III of the European Union General Data Protection Regulation (“GDPR”), you may submit your application to Datnes Bilişim A.Ş. (Turkey) in accordance with this form and one of the methods described below.

Method

Contact Information

Description

Hand Delivery

Cevizli Mah. Bağdat Cad. Turanlı Plaza No: 511/1 Maltepe/İstanbul

During the hand delivery of the Personal Data Application Form, please have one of the documents indicating your identity such as driver’s license, identity card, passport, etc. with you.

Notarized Shipping

Cevizli Mah. Bağdat Cad. Turanlı Plaza No: 511/1 Maltepe/İstanbul

In case of sending notarized documents of the Personal Data Application Form; the day the cargo reaches Datnes is foreseen as the processing date. In this context, your cargo must be sent with registered return receipt.

Mail

[email protected]

After the Personal Data Application Form is sent to us by e-mail, identity verification can be made by checking the systems or by contacting us to confirm your identity information.

Pursuant to paragraph 2 of Article 13 of the Law, your applications submitted to us will be responded within 30 (thirty) days from the date of receipt of your request, depending on the nature of the request. Our responses will be delivered to you in writing or electronically in accordance with the provision of Article 13 of the relevant Law.

Your Identity and Contact Information / Your Identity And Contact Information

Please fill in the fields below so that we can contact you and verify your identity.

Name-Surname/Name Surname

T.R. Identity Number /

Passport Number /

TR Identity No

Address for Notification /

Notification Address (Optional)

Cell Phone / GMS

E-mail Address / E-mail Address

Applicant Data Controller /

Applied Data Supervisor

Please indicate your relationship with our Company (customer, business partner, prospective employee, former employee, employee of a third party company, shareholder, etc.)

………………………………………………………………………………………………………………………………………………………………………………………………………

The Unit you are in contact with within our company : …………………………………..
Subject : …………………………………………………………………………………..
Please specify your request under the Law in detail:

…………………………………………………………………………………………………………………………………………………………………………………………

Please select the method by which you will be notified of our response to your application:
I want it sent to my address.
I want it sent to my e-mail address.
I want to receive it by hand (In case it is received by proxy, a notarized power of attorney or authorization certificate is required).

This application form has been issued in order to determine your relationship with our Company, to determine your personal data processed by our Company, if any, and to respond to your relevant application correctly and within the legal period.

In order to eliminate the legal risks that may arise from unlawful and unfair data sharing and especially to ensure the security of your personal data, our Company reserves the right to request additional documents and information (copy of identity card or driver’s license, etc.) for identification and authorization.

In the event that the information regarding your requests submitted within the scope of the form is not correct and up-to-date or an unauthorized application is made, our Company does not accept any liability for the requests arising from such incorrect information or unauthorized application.

Applicant (Personal Data Owner)

Name and Surname:

Date of Application:

Signature:

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