Prof. Dr. Şadıman Kıykaç Altınbaş
1. General
This Application Form has been prepared by Prof. Dr. Şadıman Kıykaç Altınbaş (the “Data Controller”), in her capacity as data controller, so that applications made by data subjects under Articles 11 and 13 of the Turkish Personal Data Protection Law No. 6698 (“KVKK”) can be assessed and concluded as quickly, effectively and thoroughly as possible.
2. Method of Application
Pursuant to Articles 11 and 13 of the KVKK and the Communiqué on the Procedures and Principles of Application to the Data Controller, you may submit your requests concerning the application of the KVKK to the Data Controller by one of the following methods:
In person: By completing and signing this Application Form with a wet signature and delivering it by hand, together with a document verifying your identity, to Kızılırmak Mah. Dumlupınar Bulv. No: 3, Next Level Ofis, A Blok, Kat: 14, No: 69, 06510 Çankaya/Ankara, Türkiye;
By post: By completing and signing this Application Form with a wet signature and sending it by registered mail with return receipt or through a notary public to Kızılırmak Mah. Dumlupınar Bulv. No: 3, Next Level Ofis, A Blok, Kat: 14, No: 69, 06510 Çankaya/Ankara, Türkiye;
Electronically: By signing this Application Form with a secure electronic signature or mobile signature, or by sending it to [email protected] from the e-mail address you have previously provided to the Data Controller and which is registered in our records.
For applications made by post or e-mail, “Request for Information under the Personal Data Protection Law” must be written on the envelope or in the subject line of the e-mail.
3. Information About the Data Subject
Please complete the fields below accurately and in full so that the necessary research and assessment regarding your application can be carried out:
| Name and Surname | |
| Turkish ID No. / Passport No. (for foreign nationals: nationality and passport no.) | |
| Address for Notification | |
| Telephone | |
The personal data you provide above are processed solely for the purposes of assessing and concluding this Application Form and contacting you.
Your relationship with the Data Controller: Please tick the appropriate option.
| ☐ Patient | ☐ Patient’s relative |
| ☐ Visitor | ☐ Employee / Job applicant |
| ☐ Business partner | ☐ Other: ……………………………… |
| ☐ My relationship with the Data Controller is ongoing as of the date of application. |
| ☐ My relationship with the Data Controller ended on …… / …… / ………… |
4. Requests of the Data Subject
Please tick the request(s) you wish to make under Article 11 of the KVKK in the table below. You must attach the relevant information and documents supporting your request to this Application Form.
| No | Request | Select |
| 1 | I would like to learn whether my personal data are being processed. | ☐ |
| 2 | If my personal data have been processed, I request information about it. | ☐ |
| 3 | I would like to learn the purpose of processing my personal data and whether they are used in accordance with that purpose. | ☐ |
| 4 | I would like to know the third parties, in Türkiye or abroad, to whom my personal data are transferred. | ☐ |
| 5 | I believe my personal data are incomplete or inaccurately processed and request their rectification. (Please attach a document showing the information to be corrected and the correct version.) | ☐ |
| 6 | I believe the reasons requiring the processing of my personal data have ceased to exist and request their erasure or destruction. | ☐ |
| 7 | I request that the actions taken to rectify, erase or destroy my incomplete or inaccurately processed personal data be notified to the third parties to whom my data have been transferred. | ☐ |
| 8 | I believe a result against me has arisen from the analysis of my processed data exclusively by automated systems, and I object to this result. | ☐ |
| 9 | I have suffered damage due to the unlawful processing of my personal data and request compensation. (Please attach documents evidencing the damage.) | ☐ |
| 10 | I would like to withdraw the explicit consent I previously gave. (Please specify the matter for which you are withdrawing consent.) | ☐ |
| Explanation of your request and any additional remarks: |
5. Method of Response
Please select how you would like to receive our response to your application:
| ☐ I would like it to be sent to my postal address. |
| ☐ I would like it to be sent to my e-mail address. |
| ☐ I would like to collect it in person. (If collected by a proxy, a notarised power of attorney or letter of authorisation is required.) |
6. Assessment of the Application and Declaration
Your application will be concluded free of charge as soon as possible and within 30 (thirty) days at the latest, depending on the nature of the request. However, if the action requires an additional cost, a fee may be charged in accordance with the tariff determined by the Personal Data Protection Board.
The Data Controller may request additional information and documents to verify the applicant’s identity. If the application is made on behalf of a third party, a notarised power of attorney or letter of authorisation must be submitted. The applicant is responsible for any liability arising from information in this form being inaccurate or out of date, or from an unauthorised application.
If your application is rejected, if you find the response insufficient, or if your application is not answered in due time, you may lodge a complaint with the Personal Data Protection Board within thirty days from the date you learn of the response and, in any event, within sixty days from the date of your application.
I declare that the information in this Application Form is accurate and complete, and I request that my application be assessed in line with the requests I have indicated above under Article 11 of the KVKK.
| Applicant (Name and Surname) | |
| Date of Application | |
| Signature |
This document is an English translation of the original Turkish text, provided for information purposes. In case of any discrepancy between the English and Turkish versions, the Turkish version shall prevail.
