Back Up Therapy — Provider Product Consent Form (V325)

Legal business name*

ABN*

Authorised representative name and position/title*

Email*

I declare I have manufacturer consent and authority on behalf of the indicated business to provide consent for the use of products listed (Y/N)*

I authorise The Back Up to include the specified product(s)in Back Up Therapy loan kits for members to borrow (Y/N)

I authorise TheBack Up to use our name, online images & brand assets, capture/use images, video of products for education and promotional purpose(Y/N)

I authorise The Back Up to use product information in therapist guides, provider contact sheets and digital communications (Y/N)

I agree to notify back up therapy in writing to withdraw permission granted; to fulfil existing bookings where there is no a safety concern (Y/N)

I agree by submitting this form, I bind the provider to the agreed Terms and Conditions listed below this consent form (Y/N)

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Back up Therapy

PO Box 137 Holland Park 4121

0478 508 807

Back Up Therapy — Provider Product Consent Form (V325)

Back up Therapy

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