Payment will be made as follows:
BUSINESS NAME for Check if Business is Registered with Georgia Secretary of State (SOS) or
INDIVIDUAL NAME for Check if NOT Registered with SOS.
Demographics for reporting purposes
MEDIA RELEASE FORM
I understand that I will be contacted by Zach Mitcham with HireSmart Cares, Inc. and I agree in
advance to coordinate with Zach to be filmed, photographed and/or recorded, and that my
likeness and/or voice may be used for a still photography marketing or video. I authorize Mark &
Anne Lackey, HireSmart Cares, Inc. and The REI Resource, LLC dba HireSmart Companies,
HireSmart Virtual Employees, & HireSmart VAs to make use of my name and/or image or
likeness, video recorded as well as any photographs of me (collectively, the “Materials”) in
marketing materials to be published in a variety of media, throughout the world, in perpetuity.
Mark & Anne Lackey with HireSmart Cares, Inc. and The REI Resource LLC may copyright and
license others to use the Materials. I acknowledge that Mark & Anne Lackey, HireSmart Cares,
Inc. and The REI Resource, LLC dba HireSmart Companies, HireSmart Virtual Employees, &
HireSmart VAs will rely on this permission potentially at substantial cost and hereby agree not to
assert any claim of any nature whatsoever against anyone relating to the exercise of
permissions granted hereunder.
I understand I have no claim to potential earnings in the form of direct or indirect contributions
and/or earnings to/of Mark & Anne Lackey, HireSmart Cares, Inc. and The REI Resource, LLC
dba HireSmart Companies, HireSmart Virtual Employees, & HireSmart VAs.
Please Complete and sign:
If Minor, Parent or Guardian - Please Complete and sign:
