News Interview TV Release Form

News Interview TV Release Form
Please complete this form to provide your consent for participating in a news interview and for the use of your likeness and statements in TV broadcasts.
Interviewee Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Interview
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Name of Interviewer or Production Company
Your Role or Relationship to the Story
Interview Topic or Subject Matter
Preferred Name or Pronunciation (if any)
Signature of Interviewee (or Parent/Guardian if under 18)
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