Date First Name (required) Last Name (required) Is this a different name than when you attended ANU? If so, what name do we have on file for you? Email (required) Degree(s)/Diploma(s) Graduate Year Employer/Externship Site Name Job Title/Position Military/Veteran? YesNo If yes, which branch WIA/Trade Act? YesNo Employer tuition assistance? YesNo May we connect with you on facebook? YesNo What is your facebook profile name? I hereby consent to the use of my likeness (through photography, drawing, video recording or other media), comments (through audio recording, print, or other media) and my “story” (including personal information concerning my background, my circumstances, my career and personal goals and accomplishments, my educational pursuits and attainments, and other biographical and educational information) by American National University, its successors, agents or assigns in advertising or promotional efforts, including but not limited to the following: direct mail letters or brochures, television, radio, newspaper advertisements, newspaper inserts, newsletters, social networking sites, and videotapes. In consideration of American National University’s taking or use of my likeness, statements, and/or “story” in its advertising or promotional efforts, whether published or not, I hereby release American National University, its officers, directors, employees, agents, successors and assigns from any liability in connection with the taking, recording, writing, compiling and use of such likeness, statements, and/or “story.” Date Signed* Signature* Complete the following only if changed from what the college has on file Address City State Zip Home Phone Work Phone
