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RELEASE FORM

Assignment: Photo/video session

City:

I, being of legal age, hereby consent, that my image and likeness as shown in the photographs, videos, and/or electronic images in which I appear, and/or audio recordings made of my voice may be used by iRolls Multimedia LLC and the team of NYheadshots.com, its assigns or successors, in any form they choose, including but not limited to internet, social media, software, pamphlets, newspapers, magazines, brochures, reports.

By signing below I acknowledge I have read, understand and agree with the release.

September 28, 2023

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Signed by Andrei Severny
Signed On: September 4, 2023

Timestamp

Audit

February 6, 2018 3:37 pm EDT

RELEASE FORM Uploaded by Andrei Severny - info@nyheadshots.com IP 100.12.241.245

July 23, 2018 2:54 pm EDT

NY Headshots - info@nyheadshots.com added by Andrei Severny - a@irolls.com as a CC'd Recipient Ip: 98.7.213.123

November 10, 2018 11:26 pm EDT

NY Headshots - info@nyheadshots.com added by Andrei Severny - a@irolls.com as a CC'd Recipient Ip: 104.162.238.42

November 10, 2018 11:28 pm EDT

NY Headshots - info@nyheadshots.com added by Andrei Severny - a@irolls.com as a CC'd Recipient Ip: 104.162.238.42

November 10, 2018 11:32 pm EDT

NY Headshots - info@nyheadshots.com added by Andrei Severny - a@irolls.com as a CC'd Recipient Ip: 104.162.238.42

January 30, 2019 12:29 pm EDT