75th ORC - Photo/Video Release Form

I hereby DENY my permission for images taken of myself during PIPSC meetings such as Regional Councils or Steward Councils, through video or digital mediums.

Name of Member (please print):

Member Signature:

Date Signed:

Please fax your completed form to the PIPSC Toronto office, attention Heather Kohli at 1.800.281.7280 or 416.487.7268.

*Please note:  all information contained in this form will remain confidential.