Media Release Form

Authorization

By completing and submitting this webform, you authorize Bank of Prairie du Sac to use, reproduce, and/or publish all written and/or visual materials, including photographs, that may pertain to you.

First Name

Last Name

Parental Release (list the names of any children included in this release)

Company or Organization Title

Address Line 1

Address Line 2

City

State

ZIP

Authorization I hereby authorize the Bank of Prairie du Sac to use, reproduce, and/or publish all written and/or visual materials, including photographs, that may pertain to me. I understand that this material may be used in various publications, advertisements, media releases, recruitment materials, or for other related endeavors. This material may also appear on the Bank of Prairie du Sac’s website and on the bank’s Facebook page.

Date