Do You Want to Tell Your Story?

For value received, the sufficieny of which is hereby acknowledged, and without any further consideration, I, the person whose name is signed (by submitting an on-line Customer Reference Consent and Release form), on behalf of myself, my heirs, executors, administrators and assigns, do freely consent to the use of and do now permit KeyTrak and its affiliates (collectively, “KeyTrak”) and its authorized agents and their successors and assigns to use in their sole discretion, the following in connection with the promotion, marketing and/or sale of the KeyTrak products and/or services:

1. My name;
2. The name of the business stated on the Customer Reference Consent and Release form ("Business");
3. All still photographs, sketches, drawings or motion pictures of me or of the Business; and
4. All written and recorded (audio and video) testimonials or statements made or given by me, or anyone in my employ or employ of the Business;

I understand that KeyTrak may use these in any publication or medium, in advertising or marketing, either in edited or unedited form as determined by KeyTrak, and that I will not receive any money or other compensation for any use described on the Customer Reference Consent and Release form. I understand that I can withdraw my consent after I sign this form by sending written notice to the KeyTrak representative listed at the bottom of this form. I understand that if I withdraw consent, KeyTrak will take reasonable steps to discontinue its use of the material within 60 days of receipt of such written notification.