Testimonial Consent Form

Testimonial Consent Form
Name
First NameLast Name
Date of Testimonial
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Testimonial Content:
I, the undersigned, hereby provide my testimonial regarding [Product/Service/Organization]. I grant permission to use my testimonial in various promotional materials, including but not limited to websites, social media, brochures, and other marketing channels.
Testimonial:
Media Release:
I understand that my testimonial may be accompanied by my name, photograph, and any other information provided in promotional materials.
Release Authorization:
I hereby authorize [Your Organization's Name] to use, reproduce, distribute, and display my testimonial in any media format without further notification or compensation.
Revocation of Consent:
I reserve the right to revoke this consent at any time by providing written notice to [Your Organization's Contact Person] at [Contact Information].
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Clear
Should be Empty: