Website / Media Release Form

Website / Media Release Form

Required to be completed with Testimonial Submission
Name:*

First NameNicknameLast Name
Birth Date:

MonthDayYear
Gender:
Phone Number:
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
Authorization and Release

Required to be completed with Testimonial Submission
What is your preference regarding the use of your name?*

I consent to the use of my complete name (as entered above).I consent to the use of my first name only.I consent to the use of my nickname only.I consent to BRWE LLC to use my Testimonial, but I wish my Name to remain anonymous (service type & location used only).I have submitted a photo with my testimonial, and consent to the use of my photograph(s) anonymously (no name will be included).
Please check the boxes regarding your preference.*

I will NOT be submitting any photos to authorize BRWE LLC to use.I authorize BRWE LLC to use my Testimonial and Name only.I authorize BRWE LLC to use my photo(s) on their website, and other social media platforms.I authorize BRWE LLC to use my Name and Photo for Testimonial Purposes only.I authorize BRWE to edit, alter, copy, or distribute the photos for social media, advertising and marketing.
Please acknowledge the following statements:*

I agree that I will not receive any monetary compensation for usage of my photographs in any media platforms.
Signature*

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Authorization and Release