Authorization and Release *

I, for good and valuable consideration, hereby irrevocably authorize NIRx Medical Technologies (LLC or GmbH) to use photographs and/or videos of me (or a model listed below, for whom I have legal authorization to review and sign this form). The receipt of which is hereby acknowledged in the submission of this online form. I authorize NIRx (and their assignees), licensees, legal representatives and transferees to use and publish photographs, pictures, portraits, videos, or images related to the specific project above in any and all forms and media and in all manners including composite images or distorted representations, and the purposes of publicity, illustration, commercial art, advertising, publishing (including publishing in electronic form or on the internet), for any product or services, or other lawful uses as may be determined by NIRx.  I further waive any and all rights to review or approve any uses of the images, any written copy or finished product. I am of full legal age and have read and fully understand the terms of this release. 

I agree

NIRx Branch *

Please check the branch of NIRx that this release form pertains to.

NIRx GmbH -Gustav-Meyer-Allee 25, 13355 Berlin

NIRx Medical Technologies, LLC - 15 Cherry Lane, Glen Head, NY 11545 U.S.A.

Date images/videos were made *

Please provide the date when the images and videos were taken, if this was over a few days, please put the first day.

MM

DD

YYYY

Name *

Please provide us with your legal name.

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Please put your legal address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am a NIRx Employee *

Yes

No

I am a NIRx Customer *

Yes

No