SAMPLE INTERVIEW RELEASE FORM

Project name: Show Me The Money Book Series - UnStuck
Date: April XX, 2010 10:30 a.m. EST
Interviewer: Chia-Li Chien

By electronically signing this form, you give your permission for any tapes and/or photographs and/or transcribed interviews made during this project to be used by Chien Associates LLC and the public for educational purposes including publications, exhibitions, World Wide Web, presentations and any available media.  You declare that Chien Associates LLC may be used without any restriction and may be copyrighted and published by the said party or entities designated by said party.


NAME OF INTERVIEWEE (print): Ms Biz Owner
NAME OF INTERVIEWEE BUSINESS: Big Biz LLC
INTERVIEWEE’S CONTACT INFORMATION:

XXXX Brookshire Street • City, State 28XXX
Phone: (704) 555-1112 • Fax: (704) 555-1113

http://www.BigBizLLCWebsite.com/
TheBoss@ BigBizLLCWebsite.com

Restriction description:
Yes    No
Keep my Business Name anonymous for any media production             X
Keep my Name anonymous any media production                              X
Keep my Personal & Company financial information anonymous    X   

SIGNATURE OF INTERVIEWEE: _____________________________________

DATE: _____________________________________

Birth Year:________________________________________

Chien Associates LLC | 13016 Eastfield Road, Suite 286, Hunterville, NC 28078 |704-268-9378