Permission Form

This form grants Ecology permission to use images and other materials.

Permission to use a photo, audio, video or quote

In submitting this form, you agree to the following:

I authorize the Washington State Department of Ecology to use my quote(s), photo(s), audio, and/or video, identified below, for educational or promotional purposes in any media, including Ecology websites.

I understand that my name may be used on these materials unless I request otherwise.

Description

What material is covered by this permission? *

Please describe the material you're allowing Ecology to use.

Who requested this material?

Please identify the Ecology project or person that requested this material.

For whom are you granting permission? *

For myself - I am 18 years of age or older
For a minor - who is under 18 years old

Contact information

Your email address *

We will send a copy of this form to the email address you provide.

Your phone number

( ) -

To request this form in an alternate format, contact Ecology's ADA Coordinator by email at ecyadacoordinator@ecy.wa.gov, or call 360-407-6831. People with impaired hearing may call Washington Relay Service at 711. People with speech disability may call TTY at 1-800-833-6384.

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