Name* First Last Email* Company / ProjectWebsite Your testimonial.....*Headshot or Image UploadPlease upload an image of yourself. I will crop and correct for use, if required. Drop files here or Consent*Authorization and Release Information I understand my testimonial as outlined above or in the video recorded of me (the “Testimonial”) and made on behalf of CBMedia, LLC (hereinafter called “The Business”) may be used in connection with publicizing and promoting The Business. I authorize The Business to use my name, brief biographical information, and the Testimonial as defined on this form or by me in this video. I hereby irrevocably authorize The Business to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Business’ programs or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against The Business for the use of the statement. In addition, I waive any right to inspect or approve the finished product, including written copy or edited video wherein my likeness or my testimonial appears. I hereby hold harmless and release The Business from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I have read the testimonial authorization and release information and give my consent for the use as indicated. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.