Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What stage is your business in? *

Concept (mostly ideas so far)

Startup (you're up and running but early)

Growth (you're established/profitable)

Release *

I do hereby give permission to The Company Lab (CO.STARTERS) and theCO, its agents, and others working under its authority, full and free use of video/photographs containing my image/likeness. I understand these images may be used for promotional, news, research and/or educational purposes. I hereby release, discharge, and hold harmless The Company Lab, theCO and its agents from any and all claims, demands, or causes of action that I may hereafter have by reason of anything contained in the photographs or video. I do further certify that I am either of legal age, or possess full legal capacity to execute the foregoing authorization and release.

I Agree

CO.STARTERS Agreement *

I understand that The Company Lab does not guarantee that I will be successful in my business. Furthermore, the benefits gained from participating in CO.STARTERS are a result of time, energy and dedication to the training program, and thus are not based solely on the completion of the coursework. I further understand and authorize The Company Lab to provide applicable information to the assigned management counselor(s). I understand that any information released to be held in strict confidence by him/her. No person will be excluded from participation in or otherwise subjected to discrimination in regard to services, programs and employment provided by the The Company Lab based on race, sex, color, national origin, sexual orientation, disability, age or religion.

I Agree