Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the Society of Transplantation (Singapore), its affiliates and agents, to use my image and/or any interview statements in its publications, advertising or other media activities. This consent includes, but is not limited to:
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Permission to interview, film, photograph, tape, or otherwise make a video and audio reproduction of me;
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Permission to use my name; and
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Permission to use quotes from the interview(s) (or excerpts of such quotes), photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other printed media, on television, radio and electronic media (including the Internet), and/or in mailings for educational and awareness.
This form no longer accepts submissions.
