Interview information and image release form

I authorize Austin Peay State University and any of its authorized agents or employees to:

Record my likeness, voice and/or information/property on a video, audio, photographic, digital, and electronic and/or any other medium.
Use my name in connection with the referenced recordings.
Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video tapes, DVD, CD-ROM, Internet/WWW) these recordings for any purpose that the University, and those acting pursuant to its authority, deem appropriate, including historical, scholarly, educational, research, commercial and non-commercial purposes.
Review my student record to be certain I am in good standing with the University and have not been subject to disciplinary action.

I release from the University, its successors and assigns, agents, employees and governing entities from any personal or proprietary right I may have in connection with such use.

I understand that the materials obtained and developed through the interview belongs to the University, that I have no right to control the use of my likeness, voice and/or information/property in the indicated materials and that I will not receive payment or any other compensation in connection with the use of the materials.

Please don't fill out this input box.

Date of interview or photoshoot*This release applies to the interview(s) conducted and information (including images) obtained on and after:

The subject matter or purpose of the interview(s):*

The interview/photoshoot was conducted by:*

First name*

Last name*

Address*

Phone number*

Email*

Certify information*

Certify

I certify that all the above information is true and I authorize Austin Peay State University and any of its authorized agents or employees to use my likeness.

Interview information and image release form

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