<Your city>, <Your state>
00 Month 2005
<City>, <State> <ZIP Code>
Dear <Company name>:
Regarding account <Account number>, in the name of <Name on account>.
This letter contains my instructions to you concerning your use and disclosure of information about me, my account with you, my actions and transactions, and all other data I may provide you or that you may gather concerning me. This includes, but is not limited to, information from my application, information you obtain from a consumer report, information you obtain to verify representations made by me, and information you obtain from any person regarding its employment, credit, or other relationship with me.
1. All such information may only be distributed or used internally by you to provide goods or services I have explicitly requested of you. You may not distribute or use such information for other purposes, except as I may request.
2. You shall protect all such information from access by or disclosure to persons not authorized by these instructions (including employees without a need to know). This protection shall include physical and procedural controls that have been proved effective at preventing unauthorized disclosure and access.
3. You may not disclose information about me to your affiliates, or any third-party company or individual, except as I may request.
4. You may not disclose any of my transaction and experience information (including creditworthiness) to your affiliates, or any third-party company or individual, except as I may request.
5. Do not send me marketing offers or surveys from your company, its affiliates, or any third-party company or individual. Please delete my name from all marketing lists and databases.
6. If you obtain or I supply any telecommunications address, including telephone number, facsimile (fax) number, e-mail address, or Web site address, you may only use such address in direct response to a specific transaction or request initiated by me.
These instructions are given in part under our agreements, the Fair Credit Reporting Act, the Gramm-Leach-Bliley Financial Services Modernization Act, the Telemarketing Sales Rule, and the Telephone Consumer Protection Act.
These instructions are effective immediately and remain in force perpetually. These instructions are binding on you, your subsidiaries, affiliates, employees, contractors, vendors, and agents; and your and their successors and assigns. Should any part of these instructions become invalidated, all other parts shall remain in force.
Please respond to me in writing confirming that you will comply with these instructions. Thank you.