Permission to Quote

Here's what I've got to say about PBSP®:

Please note if this is not enough space you may opt to send us a separate email in addition to this form to contact@PBSP®.com or PBSP®1@aol.com 

I,
of ,
grant Albert Pesso and Diane Boyden-Pesso, Pesso Boyden System Psychomotor, PBSP®, and the Psychomotor Institute permission to quote from my message typed (or handwritten, if printed and mailed in) below on this form describing my experiences with PBSP®.  

Keep my name ANONYMOUS.
You may use my name along with my quote.

You may (also) describe me am in the way I list below. (Examples:  "a home care provider for my family",  "a lawyer in San Francisco", or "a sex abuse survivor", or "a corporate executive seeking to improve my performance at work", "a Vet returning from Iraq")

I grant FULL PERMISSION to use the following quote/comment from me on the PBSP® website and/or other websites associated with PBSP® or Albert Pesso and Diane Boyden-Pesso, in any printed advertising, promotional or training material and verbally at any conference, presentation, workshop or training program including use in sound and video reproductions.
OR
I grant permission to use my above quote/comment with the following RESTRICTIONS OR LIMITATIONS:

If you would like your contact information to be shown with your quote, please write it in the box below exactly as you would want it to appear.  Please also add any links (complete web address) or other information you might like to share with whoever reads your quote. Please note that we hold the right to display or not display this information with your quote.

I will print out and mail this form with my quote (handwritten, typed, or printed) to PBSP®, Strolling Woods, Lake Shore Drive, Franklin, NH 03235, USA.

Signed: ________________________________________________

 Date: ____________________________

------------------Filling out the form below this line is optional---------------------

Your Contact Information for our database (not to show with quote)

First Name:   Last Name:  
Title:
Organization Name:
Address:  
Extra Address:
City: State: Zip Code:
Country:
(H) Phone: (B) Phone:
Cell Phone / mobile:
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Need Help?

Call  (603) 934-2737 and/or email  contact@PBSP®.com, or PBSP®1@aol.com with any questions or comments you have.