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Account Credentials

Username *

Password *

Full Name *

First

Last

Title *

Company Name *

Company Phone *

Company Email *

Ticker Symbol (if available)

Industry

Website

Personal Email

I further authorize the individuals listed below to request and approve content on behalf of the above public company:

Name

Phone

Name

Phone

Name

Phone

Authorization *

I authorize MCAP MEDIA, LLC to issue a company wirepress release on our behalf and using our public ticker symbol. I have authority to legally bind the company and to provide this authorization*. This form may be digitally signed or signed by hand. Authorization form MUST be signed by a C-level of below public company and MUST include a valid company email, title and contact details from the company domain prior to MCAP MEDIA, LLC providing Wire Press Releases. NO Yahoo, Hotmail, Gmail or personal email will accepted; nor will ADMIN@ IR@, INFO@ or PR@ via company email.

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