{{ page.title }}

{{ page.content }}
{% assign action = 'https://docs.google.com/forms/u/1/d/e/1FAIpQLSctaADJBwLa3-cYSYymn92HwZP_6kHBO9BrQ20J_xHa0caRPw/formResponse' %}
{% include 'component-input' with label: 'First Name', placeholder: 'First Name', name: 'entry.1322886878', type: 'text', required: true, className: 'terracycle__input fa' %} {% include 'component-input' with label: 'Last Name', placeholder: 'Last Name', name: 'entry.1908623782', type: 'text', required: true, className: 'terracycle__input fa' %}
{% include 'component-input' with label: 'Email Address', placeholder: 'Email Address', name: 'entry.439651883', type: 'email', required: true, className: 'terracycle__input fa' %} {% include 'component-input' with label: 'Phone Number', placeholder: 'Phone Number', name: 'entry.311026031', type: 'tel', required: true, className: 'terracycle__input fa' %}
{% include 'component-input' with label: 'Address Line 1', placeholder: 'Address Line 1', name: 'entry.829836872', type: 'text', required: true, className: 'terracycle__input fa' %}
{% include 'component-input' with label: 'Address Line 2', placeholder: 'Address Line 2', name: 'entry.1100590344', type: 'text', className: 'terracycle__input fa' %}
{% include 'component-input' with label: 'City', placeholder: 'City', name: 'entry.709315315', type: 'text', required: true, className: 'terracycle__input fa' %} {% include 'state-select' with placeholder: 'STATE', name: 'entry.1254129686', required: true, className: 'terracycle__input fa' %} {% include 'component-input' with label: 'Zip', placeholder: 'Zip', name: 'entry.1520468655', type: 'text', required: true, className: 'terracycle__input fa' %}

Select Request Type:

Request Details:

Describe the information you would like us to supply/delete. Please provide any relevant details you think will help us to identify the information (including the method by which you submitted the information).

{% include 'component-input' with label: 'Request Details', placeholder: 'Request Details', name: 'entry.1087975387', type: 'text', required: true, className: 'terracycle__input' %}

I, confirm that I have read and understood the terms of this data request form and certify that the information I have provided in this form to ILIA Beauty is true. I understand that it is necessary for ILIA Beauty to confirm my identity. I further understand that it may be necessary for ILIA Beauty to obtain more detailed information in order to verify identity and/or locate the correct personal information. If my identity cannot be verified, ILIA Beauty reserves the right to deny my request.

By submitting this form, you agree to the terms noted above.

{% include 'component-button' with tag: 'button', type: 'submit', cta: 'Submit', className: 'btn btn--quicksand' %}

Submitted. Please allow for 2 business days while we process your request.