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2. Name*
3. Email Address*
5. Business Name*
7. Business Address
9. Phone Number*
11. Tell Us Your Story
13. Image to Share?

    Upload the image you would like to share.

15. Link to Share?

    Paste the link to a video, photo, YouTube, or Dropbox file you would like to share.

17. Terms

    By signing below, I affirm give permission to Georgia's Rome to use the story, photos and videos which I have submitted in various media formats for an unlimited amount of time and at no cost to Georgia's Rome. 

19. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
21. Electronic Signature*
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23. 1. Receive an email copy of this form.
24. Email address

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25. Submit

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