Public Figure Release Statement Request

Public Figure's Full Name

First NameLast Name

Public Figure's Email Address

example@example.com

Public Figure's Phone Number

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

Public Figure's Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Requester’s Full Name

First NameLast Name

Requester’s Organization (if any)

Requester’s Email Address

example@example.com

Project Title or Description

What is being requested for release?

Other

Intended Use

Duration of Release

If limited time, please specify dates

Territory of Use

Is compensation offered for this release?

If yes, specify compensation amount or terms

Additional Notes or Special Instructions

Signature of Public Figure