Media Access Authorization Form
Request permission to use a person’s media content. Please complete all sections to authorize media usage.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Media Content
*
Intended Use or Purpose of Media
*
Authorization Declaration
*
By signing below, I authorize the use of my media content as described above.
*
Submit Authorization
Submit Authorization
Should be Empty: