Media Release Form

Media Release Permissions

I hereby give permission to AFSCME to use my name and likeness in all forms and media for advertising, trade, and anyother lawful purposes.

This includes the unrestricted right and permission to use, re-use, publish, and republish photographic portraits,
pictures, film footage or video content of me or in which I may be included intact or in part, without restriction as to changes or transformations in conjunction with my own or a fictitious name, or reproduction hereof in color or otherwise, made through any and all media now or hereafter known illustration, art, promotion, advertising, trade, or any other purpose whatsoever.

Home Address *

First name *

Last name *

Address 1 *

Address 2

City *

State *

ZIP code *

Personal Email *

Cell Phone *

Signature

Date *

Month

Day

Year

AFSCME District Council 36

Media Release Form