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First Name:
Last Name:
Zip Code:
Phone Number:
Email Address:
Location of photograph:
Photo category:
Brief description of photo:
I agree to the terms of the license agreement.

License Agreement: By submitting to AnchorBank, a division of Old National Bank, ("we" or "us") the attached photograph(s), you acknowledge that our Terms of Service apply to your submission(s) and our use of this material. You also hereby grant to us, our affiliates and licensees, a royalty-free, non-exclusive, perpetual, worldwide right to copy, edit, adapt, distribute, perform, display, and/or use, these photographic images, including any derivative works created from these materials, in whole or in part, for any purpose and in any manner, form, format or medium, now known or later developed, including without limitation, on the Internet, in print and on-air, and/or in any advertising or promotions. In addition, you grant to AnchorBank, a division of Old National Bank, the royalty-free, non-exclusive, perpetual, worldwide right for the possible use of your name and biographical information in connection with the use of these materials. You also grant to us the right to sublicense to any person or entity the unrestricted right to exercise any of the rights you have granted to us in this agreement.

You represent that you are at least 18 years old, that you have the right to grant us all the rights granted herein and that these materials are your original work and are not owned by any other person or entity. You also represent that the materials, the creation of the materials, and the use of the materials do not violate any law or regulation and do not infringe the rights of any person or entity, including, but not limited to, any copyright or trademark rights and/or rights of privacy or publicity. You agree to indemnify and hold harmless AnchorBank, a division of Old National Bank, and its affiliates, from any loss, claim, damage or expense arising from the use of these materials or your breach of this agreement, including the above representations.

You understand and agree that you will not have any right of approval over the use of these materials pursuant to this agreement and you will not receive any compensation as a result of any use of the materials or the rights granted pursuant to this agreement. You also understand and agree that nothing in this agreement obligates AnchorBank, fsb to use these items. This agreement constitutes the entire agreement between AnchorBank, a division of Old National Bank, and you with respect to the subject matter of the agreement and supersedes all previous and contemporaneous agreements, proposals and communications, written oral. This agreement shall be governed by and construed in accordance with the laws of the State of Wisconsin without giving effect to any principles or conflicts of law. 

You hereby agree to the foregoing by checking the indicated box on the form.