PINAR SARIYILDIZ APPLICATION FORM TO THE DATA CONTROLLER

Under the Personal Data Protection Law No. 6698 ("Law"), individuals whose personal data is processed ("Data Subject") are granted certain rights regarding the processing of their personal data under Article 11 of the Law.

Pursuant to Article 13, Paragraph 1 of the Law, applications concerning these rights must be submitted to our Clinic, as the data controller, in writing or through other methods determined by the Personal Data Protection Board ("Board").

In this context, applications to our clinic that are to be submitted "in writing" must be made by printing out this form and delivering it via one of the following methods:

By personal application of the applicant,
Through a notary,
By signing the form with a "secure electronic signature" as defined in the Electronic Signature Law No. 5070 and sending it to the Clinic’s registered electronic mail address,
By Mobile Signature or via email submission.

Application Method	Address for Application Submission	Information to Be Included in the Application
In-Person Application (The relevant person must apply in person with an identity-verifying document.)	Harbiye Mah. Mim Kemal Öke Cad. Melek Ap. No.19 İç Kapı No.2 Şişli/İstanbul Türkiye	The envelope must be labeled as "Personal Data Protection Law Information Request."
Registered Mail with Return Receipt or Through Notary	Harbiye Mah. Mim Kemal Öke Cad. Melek Ap. No.19 İç Kapı No.2 Şişli/İstanbul İstanbul	The envelope must be labeled as "Personal Data Protection Law Information Request."
Application via E-mail [By using the e-mail address previously provided to the data controller and registered in the data controller’s system]	…[●]	The subject line of the e-mail must be "Personal Data Protection Law Information Request."

The channels specified above are "written" application channels in accordance with Article 13, Paragraph 1 of the Law. Once other methods determined by the Board are announced, our clinic will inform about how applications will be received through these methods as well.

PINAR SARIYILDIZ

Identity and contact information of the data subject submitting the application:

Full Name	:	…………………………………………………………………………………………..
Date of Birth and Citizenship Number	:	……../………. / ……….. ……………………………………………………..
For Foreign Nationals: Nationality	:	……………………………………………………………………………………………
For Foreign Nationals: Passport Number	:	……………………………………………………………………………………………
For Foreign Nationals: Identification Number (if available)	:	……………………………………………………………………………………………
Phone Number – Fax Number (if available)	:	…………………………………………………………………………………………………………………………………………………………………………
Email Address	:	…………………………………………………………………………………………………………………………………………………………………………
Address	:	…………………………………………………………………………………………………………………………………………………………………………