Employee Press Release Form

EMPLOYEE PRESS RELEASE AUTHORIZATION

Employee Information

Position Information

Press Release Metadata

Proposed publication date:

This release is subject to embargo: Yes    No

If embargoed, embargo date/time (if applicable):

Press Release Content

Media Permissions

I grant the Company the right to use the following, as indicated below (check applicable boxes):

Use of my name and job title
Use of my photograph(s) and video image(s)
Use of my recorded voice/audio
Use of biographical and employment information as provided herein
Right to reproduce and distribute in print, digital, and social media channels

Limitations, restrictions, or special instructions regarding use (if any):

Employment History (for bio verification)

Employer 1

Employer 2

Education

References (for verification)

Reference 1

Reference 2

Reference 3

Legal Authorizations and Certifications

By signing below I certify that the biographical and employment information provided in this form is true and accurate to the best of my knowledge. I authorize the Company and its authorized representatives to verify any information contained herein, including contacting prior employers and educational institutions for the purposes of factual verification of biography for the press release.

Grant of Rights and Release

I hereby grant the Company, its affiliates, agents, licensees and assigns a perpetual, worldwide, royalty-free, irrevocable license to reproduce, distribute, publish, display, adapt, modify and otherwise use my name, job title, photograph(s), video image(s), voice recordings, biographical information and any quotations attributed to me in connection with the press release and any promotional or archival uses related thereto. I release and hold harmless the Company from any claims, demands or causes of action arising out of or in connection with such uses, including claims for defamation, invasion of privacy, right of publicity, or infringement of moral rights, to the extent permitted by law.

I acknowledge that I will not receive additional compensation for the uses described above and that the Company may use the materials in whole or in part, alone or in combination with other materials, in any and all media now known or hereafter devised.

Revocation: I understand that I may withdraw this consent only in writing. Such revocation will not apply to uses already undertaken or to materials already distributed or published prior to the date the Company receives my written revocation.

Authorization to Verify: I expressly authorize the Company to contact the references and prior employers listed above for the purpose of verifying information intended for publication in the press release.

Affirmation: I certify that all information provided on this form is true and complete and that I have the authority to grant the rights and permissions stated herein.

Company Use / Approvals (for internal routing)

Communications contact name:    Date approved:

HR contact name:    Date reviewed:

Equal Opportunity and At-Will Notice

Equal Opportunity: The Company is an equal opportunity employer. Inclusion of an employee in a press release shall not be construed as a guarantee of employment status or benefits beyond existing terms of employment.

At-Will Employment: Nothing in this authorization alters the at-will nature of the employment relationship where applicable, nor does it constitute an employment contract.

Signatures and Consent

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