Motorcycle Safety Video Submissions

Release Form

I hereby consent to the Commonwealth of Pennsylvania, Department of Transportation (“PennDOT”), using my using my Motorcycle Safety Content Submission ("Content"). I hereby consent to PennDOT reproducing the Content in any media.

I consent to PennDOT being the exclusive owner of any intellectual property rights as they relate to any original material it creates by utilizing the Content.

I am aware that the Content will be the property of PennDOT for the purpose of sharing it with a wider audience as it relates to a safety topic.

I agree this release shall be effective as of the date of signature below and remain in effect indefinitely.

I have read and fully understand this release and intend to be legally bound by its terms.

Required fields are marked with an asterisk.(*)

Electronic Submission. Under penalties of perjury I certify that I am the person accessing this web page and submitting the Department of Transportation. By checking this box and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature. I understand that I can be prosecuted if I provide false or misleading information. RELEASE OF INFORMATION: I verify that the information provided in this document is true and accurate. I understand that I may be subject to the criminal penalties prescribed by 18 Pa. C.S.A. Section 4904 for unsworn falsifications to authorities if there are false statements in this document.