Newmarket Sports Hall of Fame Inductee Nomination Form

TO: THE NEWMARKET SPORTS HALL OF FAME
RE: CONFIDENTIAL INFORMATION RE: DECEASED INDUCTEE
_________________________________________
(print Inductee’s full name)
I, ____________________________________________, hereby declare that I, as the
(print your full name)
duly authorized personal representative of the estate of
______________________________
print deceased Inductee’s full name)
hereby consent and agree that the Newmarket Hall of Fame may collect and disseminate
personal information regarding the Inductee as set out above, for all promotional
displays, media coverage in any format, including print and electronic media, certificates,
exhibits, biographies, etc.
It is understood and agreed that no further permission beyond this consent must be sought
from the personal representative of the deceased’s estate with respect to the use of the
Inductee’s
personal information for the purposes set out herein.
DATED AT Newmarket this _____ day of __________________, 20____.
Personal Representative: ______________________________________________
Relationship to the Deceased Inductee: __________________________________
Personal Representative’s Address: _____________________________________
Personal Representative Telephone: _____________________________________