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SECURE INTAKE

Client Intake Form

Complete the fields below for your selected services. We'll show only the sections relevant to your order.

SECURITY: This form is transmitted over HTTPS. We collect only what is necessary to perform your selected service. All data is handled per our Privacy Policy.

CLIENT INFORMATION

Required

Full Legal Name * Full legal name is required.

Date of Birth * Date of birth is required.

Email Address * A valid email address is required.

Phone Number * Phone number is required.

State of Residence * Please select your state of residence.

Your state determines which privacy laws we can cite. Clients in states with comprehensive privacy laws receive the strongest legal leverage for removal requests.

Current Street Address * Street address is required.

City * City is required.

State *

ZIP * ZIP code is required.

Additional Details (optional — helps us find more listings) ▼

SERVICE SELECTION & CONCERNS

Required

What is your primary concern? * Please select your primary concern.

Additional Context (optional)

YOUR SELECTED SERVICES

Total:

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FACIAL RECOGNITION DETAILS

ADD-ON

We search 5 facial recognition databases for your face and submit opt-out requests where found.

After you submit this form, you'll receive a confirmation email with instructions to securely submit your photos and ID.

What we'll need:

3-5 clear face photos (front, left profile, right profile)
Anonymized ID scan (optional — cover name/address/ID number, leave photo visible)

Photos are sent via email reply — never uploaded to a web form.

VEHICLE PRIVACY DETAILS

ADD-ON

We check plate lookup sites, map nearby license plate readers, and audit connected car data sharing.

LICENSE PLATE NUMBER * License plate number is required for vehicle privacy service.

PLATE STATE *

VEHICLE YEAR / MAKE / MODEL (optional)

CONNECTED CAR PLATFORM

PRIMARY AREA OF TRAVEL (for ALPR camera mapping)

DATING APP DETAILS

ADD-ON

We submit data deletion requests and document biometric data stored by dating platforms.

WHICH APPS? (check all that apply)

Tinder

Bumble

Hinge

OkCupid

Grindr

Match.com

Coffee Meets Bagel

Other

SOCIAL MEDIA DETAILS

ADD-ON

We audit your public presence, document privacy risks, and provide platform-specific hardening recommendations.

WHICH PLATFORMS? (check all that apply) HANDLES / PROFILE URLS DEVICE TYPE (for ad tracking opt-out)

AUTHORIZATION & ACKNOWLEDGMENTS

Dark Scrub — Alaska Business License #2230644 — EIN 41-4418205

By completing the acknowledgments below, you authorize Dark Scrub to act on your behalf for the purpose of submitting data deletion, opt-out, and suppression requests.

I confirm that I am the individual whose personal information will be submitted for removal, or I am the legal guardian/authorized representative of that individual. I understand that Dark Scrub will submit opt-out, deletion, and suppression requests to data brokers, facial recognition databases, plate lookup services, and other data holders on my behalf, as determined by my selected service tier and coverage areas. I understand that data removal is not permanent. Data brokers continuously re-acquire personal information from public records, commercial databases, and data partnerships. My data may reappear after removal. I understand that results vary by state and data source. Not all data brokers honor deletion requests. Dark Scrub will document refusals and escalate where possible, but cannot guarantee removal from every source. I authorize Dark Scrub to use the personal information I provide solely for identifying and removing my data from third-party databases. My information will not be shared, sold, or used for any other purpose. I understand that some data brokers require identity verification before processing deletion requests. I authorize Dark Scrub to submit my identifying information to these brokers solely for verification and removal purposes. I have read and agree to the Dark Scrub Privacy Policy. Please check all authorization boxes above.

ELECTRONIC SIGNATURE

TYPE YOUR FULL LEGAL NAME EXACTLY AS ENTERED ABOVE TO SIGN * Please type your full legal name to sign. Signature must match the full legal name entered above.

DATE

By typing my name above, I am signing this form electronically. I agree that my electronic signature is the legal equivalent of my handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001 et seq.) and the Uniform Electronic Transactions Act (UETA).

Client Intake Form

Start by selecting your services

Your Selected Services

CLIENT INFORMATION

SERVICE SELECTION & CONCERNS

YOUR SELECTED SERVICES

FACIAL RECOGNITION DETAILS

VEHICLE PRIVACY DETAILS

DATING APP DETAILS

SOCIAL MEDIA DETAILS

AUTHORIZATION & ACKNOWLEDGMENTS

ELECTRONIC SIGNATURE

✓ INTAKE SUBMITTED