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* 1. Please provide your full legal name:

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* 2. Please provide your preferred telephone number:

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* 3. Please provide your preferred email address:

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* 4. I hereby grant to NSGC perpetually, exclusively, and for all media (including print, film, slides, video, websites, social media, and any other electronic medium), the right to use and incorporate (alone or together with other materials), as a result of my submission of this photograph.

I confirm that no proprietary information is being shared.

NSGC or its designee shall have complete ownership of the Property in which I appear, including copyright interests, and I acknowledge that I have no interest or ownership in the Property or its copyright. This grant includes the right to use the Property for promoting or publicizing any of the uses.

I hereby release NSGC and their legal representatives and assigns from all claims and liability relating to said Property.

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* 5. Please upload a high resolution headshot below:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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