Public Statement Release Form
Submit your details and authorize the release of your public statement.
Full Name
*
First Name
Last Name
Organization or Affiliation
*
Job Title or Role
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Statement Title or Subject
*
Public Statement Content
*
Intended Publication Channel or Audience
*
Preferred Publication Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Release Authorization
I hereby authorize the above statement to be released publicly as submitted. I affirm that I have the authority to make this statement and grant permission for its publication and distribution through the specified channels. I understand that by signing below, I waive any claims regarding the use of this statement as described.
Signature
*
Submit Release
Submit Release
Should be Empty: