Consent Form Consent I CONSENT to the use of my name and/or my likeness for the purpose of advertising or trade by New York State Department of Economic Development (“DED”) or anyone authorized by that Department to act on its behalf. “My likeness” includes a photograph, videotape recording, film or artistic rendering of me, a recording of my voice, and/or reproductions of any of these. I agree that the actual material involved, such as a photograph, negative, plate, videotape recording, film or audio recording is and shall continue to be the property of the New York State Department of Economic Development. I GRANT PERMISSION TO New York State Department of Economic Development to use my person, company name and information regarding the general nature of my business and the services provided to me by a representative of the New York State Department of Economic Development. I UNDERSTAND AND AGREE that I will not be compensated in any way for the use of my name and/or likeness by the New York State Department of Economic Development. I also understand that the New York State Department of Economic Development may incur expenses in connection with the recording or reproduction of my name and/or likeness, and that I am free from any responsibility for these expenses. IF MORE THAN ONE (1) PERSON signs this consent, each person hereby agrees to the preceding provisions. IF THE PERSON WHO IS BEING PHOTOGRAPHED, FILMED, VIDEOTAPED OR RECORDED IS UNDER AGE 18, HIS/HER GUARDIAN MUST SIGN BELOW INSTEADName* First Last Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Signature* Δ
