SMART Scholarship SMART Media Release

SMART Scholarship-for-Service Program

20___

SMART MEDIA RELEASE

OMB No.
OMB approval expires

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2192a, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 5 U.S.C. 3304, Competitive service
examinations; 20 U.S.C. 17, National Defense Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPLE PURPOSE(S): To record a SMART Participant’s agreement to permit the use of their image, name and voice publications and/or other productions related
to the SMART Program.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To academic institutions for the
purpose of providing progress reports for applicants and participants; to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C.
1681a(f)) or the Federal Claims Collection Act of 1966 (31 U.S.C. 3701(a)(3)). The purpose of this disclosure is to aid in the collection of outstanding debts owed to the
Federal government, typically to provide an incentive for debtors to repay delinquent Federal government debts by making these debts part of their credit records;
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure When Requesting Information
Routine Use, Disclosure of Requested Information Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the
National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use.
The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices
may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
The applicable Privacy Act System of Records Notice is DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information Management
System, found at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570592/dusda-14.aspx
DISCLOSURE: Voluntary.

This Release and License to Use Image, Name and/or Voice (the “Release”) is used to obtain permission from individuals to use their
image or visual likeness, name, and voice in publications and/or other productions related to the Science, Mathematics, and
Research for Transformation Scholarship-for-Service Program (“SMART”).
I, the undersigned, hereby grant SMART and/or its agents, employees, licensees and/or assignees permission to use, exploit, adapt,
modify, reproduce, distribute, publicly perform and/or display, in any form now known or later developed, my image or visual
likeness, my name, my voice, and information related to my experience with SMART, including but not limited to the dates of
participation, the name and location of the academic institution for which I receive or received funding, the benefits and/or the
monetary value of the benefits I received under SMART, degree I am pursuing or have earned, location and job description of
internship and/or post-graduation employment, mentor experience, and general statements relating to working for the federal
government (collectively the “Information”) throughout the world by incorporating it or them into publications, catalogues,
brochures, books, magazines, photo exhibits, motion picture films, presentations, internet sites, videotapes, compact discs, other
media, and/or commercial, informational, educational, advertising, or promotional materials (collectively the “Works”).
I hereby release, indemnify, hold harmless, and defend, SMART and/or its agents, employees, licensees and/or assignees from any
and all claims, I or any third party, may have now or in the future for invasion of privacy, right of publicity, copyright infringement,
defamation, and/or any other cause of action arising out of the use, exploitation, reproduction, adaptation, distribution, broadcast,
performance, or display of the Information.
I hereby waive any and all rights to inspect and/or to approve any and all Works that may be created using the Information. I hereby
waive any and all claims or potential claims related to the use to which the Information may be applied. The Information may be
used at the sole discretion of SMART and/or its agents, employees, licensees and/or assignees, with or without my name or with a
fictitious name, and with fictitious or accurate biographical material, alone or in conjunction with any other material of any kind or
nature except that SMART and its agents, employees, licensees and/or assignees shall not use the Information for any criminal or
illegal purpose, or in a manner inconsistent with community standards of decency.
I understand and agree that SMART is and shall be the exclusive owner of all right, title, and interest, including copyright, in the
Works, and any commercial, informational, educational, advertising, or promotional materials containing the Information.
I am of full legal age, I have read this Release, and I am fully familiar with its contents.

Printed Name: ___________________________________
Signature: ______________________________________ Date: _______________________
Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to the Department of Defense, Washington headquarters Services, Executive Services Directorate, Directives Division, 4800
Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 OMB Control Number: 0704-0466. Respondents should be aware that notwithstanding any other provisions of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

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SMART Document, revised 2015