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Testimonial Release Form

  1. NeighborhoodSrvsLogo_Blue
  2. Testimonial Statement:
  3. Authorization and Release Information
    The City of Balch Springs appreciates and values your input in regard to interaction of the public with the City’s Neighborhood Services Department (“the Department”) and its efforts to assist citizens of the City. Accordingly, the City would like to have authority to use your testimonial statement, as well as your name and photo in connection with the Department’s work, but will not do so without your written permission. Accordingly, please complete the authorization below in connection with publicizing and promoting, the department.
  4. I authorize the department to use my (check those to which your authorization applies):*
    in connection with the Department’s publicizing of its programs. I hereby authorize the Department to copy, exhibit, publish, or distribute the items identified above in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against the City of Balch Springs or the department for the use of this statement.
  5. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  6. Leave This Blank:

  7. This field is not part of the form submission.