Marketing Release Authorization Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Organization or Company Name (if applicable)

Role or Relationship to the Organization (if applicable)

Please select the type(s) of material you authorize for marketing use:

Briefly describe the content or material being released (e.g., event name, testimonial topic, project):

Where may your authorized material be used?

Other

Duration of Authorization

If you selected 'Other' for duration, please specify:

Please list any restrictions or special instructions regarding the use of your material (optional):

Signature (please sign below to confirm your authorization)

Date of Authorization

Date