Authorization to allow Genesis Media to access your social media account information. Name * First Name Last Name Email * Website http:// Social Media Accounts * Check all that apply: Facebook Twitter Instagram TickTock Google Youtube Mail Chimp Web Host Other Facebook Login ID & Password Instagram Login ID & Password Twitter Login ID & Password TikTok Login ID & Password Google/Gmail Login ID & Password YouTube Login ID & Password MailChimp Login ID & Password Hosting Service/Domain Host Login ID & Password Other Login ID & Password Consent / Release Agreement Consent to the Agreement * I Agree Electronic Signature * By typing my name below I am agreeing to sign and date this agreement electronically. Date * MM DD YYYY Thank you!
