2014 Designation Promotional Campaign Participation Compliance Form This signed compliance form indicates that you have obtained permission to be included in the 2014 promotional campaign representing the _________________________ designation. You will be featured in various forms of media – including print, online, and out of home advertising. Being a part of the promotional campaign could include the following: Interviews - in print and online Profiles in magazines Live Q&A sessions Webinar panel of different designation holders to the public on what your designations mean Media interviews as a spokesperson Video gallery These advertisements are intended to build the profile of designation holders as trusted and experienced financial professionals. By featuring successful designation holders in the ads, we demonstrate the value of your credential. The advertisements will include (please fill out below): 1. A photograph of you – see sample advertisement 2. Your full name:__________________________________ 3. Your current title: ______________________________________________ 4. Current company:________________________________________________ If you grant us permission to feature you in the campaign, please sign below. We also require compliance sign-off from your company allowing us to feature you in the ad, including your title and the name of your current employer. Please sign off and return to [email protected] or fax back to 1-866-866-2660 Attn: Amy Umpleby. _________________________ _________________________ _________________________ Designation Holder: Full Name (Printed) Signature Date _________________________ _________________________ _________________________ Compliance Officer: Name (Printed) Signature Date