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Български1. GENERAL EXPLANATION
This form has been prepared for you to exercise your rights under Article 11 of the Personal Data Protection Law No. 6698 (KVKK) regarding your personal data with ÇAVUŞDENT ORAL AND DENTAL HEALTH POLYCLINIC ("Polyclinic").
In accordance with the "Communiqué on the Procedures and Principles of Application to the Data Controller", applications are processed after identity verification, and your request will be concluded free of charge within a maximum of 30 (thirty) days.
For applications to be made by third parties on behalf of the personal data owner, a notarized special power of attorney issued on behalf of the data owner must be attached to the application.
2. INFORMATION ABOUT THE DATA CONTROLLER
Information Field | Information |
| Title | Çavuşdent Oral and Dental Health Polyclinic |
| Address | Muhittin Mah. Salih Omurtak Cad. Mühendis Kamil İnan Apt, No:63 İç Kapı No:1 Çorlu/Tekirdağ |
| Phone | 0 531 849 56 59 | 0 282 673 48 96 |
| info@cavusdent.com |
3. APPLICATION METHODS
Method | Explanation |
| Application in Person | You can apply in person by presenting your identity card to the address: Muhittin Mah. Salih Omurtak Cad. Mühendis Kamil İnan Apt, No:63 İç Kapı No:1 Çorlu/Tekirdağ. |
| Mail / Notary Public | You can send your application form with wet signature to the postal address above or via a notary public. |
| You can send it to info@cavusdent.com with your registered electronic mail address or secure electronic signature. It is mandatory to write "KVKK Application" in the subject line. |
4. IDENTITY INFORMATION OF THE APPLICANT
Please fill in the fields below completely and accurately. Applications containing incomplete or incorrect information cannot be processed.
Identity Field | Information |
| Name Surname | |
| TR Identity Number | |
| Phone Number | |
| E-mail Address | |
| Correspondence Address |
If the person making the application is the data owner themselves, check the box below:
☐ | I am the personal data owner myself. |
If you are making the application by proxy, please fill in the fields below:
| Proxy / Representative Name Surname | |
| Date of Power of Attorney | |
| Type of Authorization |
* For applications made by proxy, the original notarized power of attorney must be attached.
5. SUBJECT OF REQUEST
Check the right or rights you wish to exercise under Article 11 of the KVKK:
☐ | I want to learn whether my personal data is processed or not. |
☐ | I request information if my personal data has been processed. |
☐ | I want to learn the purpose of processing my personal data and whether they are used in accordance with their purpose. |
☐ | I want to know the third parties to whom my personal data is transferred domestically or abroad. |
☐ | I request the correction of my personal data if it has been processed incompletely or inaccurately. |
☐ | I request the deletion or destruction of my personal data in the event that the reasons requiring its processing disappear, despite being processed in accordance with the KVKK. |
☐ | I request that the correction/deletion/destruction processes be notified to the third parties to whom my data has been transferred. |
☐ | I object to the occurrence of a result against me by analyzing my processed data exclusively through automated systems. |
☐ | I request compensation for the damage I suffered due to the unlawful processing of my personal data. |
6. EXPLANATION OF REQUEST
Please explain your request in detail:
7. PREFERENCES REGARDING THE RESPONSE TO THE APPLICATION
Check the method by which you would like the response to be delivered to you:
☐ | I want it sent to my correspondence address via mail/cargo. | ☐ | I want it sent electronically to my registered e-mail address. |
☐ | I want to receive it by hand in person from our Polyclinic. | ||
8. DECLARATION AND SIGNATURE
I accept and declare that all the information I have declared in this application is accurate, complete, and up-to-date; and that any responsibility arising from my application containing incorrect or incomplete information belongs to me.
Application Date: . . . . . / . . . . . / 2 0 . . . . | Name Surname:
| Signature:
|
9. FOR POLYCLINIC INTERNAL USE
This section will be filled out only by authorized polyclinic personnel.
Field | Information |
| Application Receipt Date | |
| Application Number | |
| Receiving Personnel | |
| Identity Verification Method | |
| Response Date | |
| Result / Notes |
