Platinum Strategic Partner Web Page

Company Name *

Personal Name Wanted Shown on Web Page *

First

Last

Cell Phone *

Office Phone *

Email *

Website address you want shown on your video page - link will be provided to your site

I would like a video on my web page *

Yes
No

I have my own video *

Yes
No

YouTube Link for Partner Provided Video

File Upload Video if Not on YouTube, etc.

Click or drag a file to this area to upload.

I want a new recorded video for my business. WCR retains all rights to video and it will only be shared for WCR purposes.

Yes
No

Address video will be shot at

Address Line 1

Address Line 2

City

State

Zip Code

Please up the photo you want used for your banner at the top of the page. *

Click or drag a file to this area to upload.

Please upload any photos you want shown, maximum 4 photos

Click or drag files to this area to upload. You can upload up to 4 files.

I certify all of these are my photos. I own the rights to these photos. I understand I will be liable if any copyright issues arise, including, but not limited to attorney fees. *

Yes
No

Tell us anything you want on your page. (You can copy and paste here if you already have something.)

Name of person filling out this form. *