Email *
Please enter a valid email address.
Next
Clear form
Never submit passwords through Google Forms.
Section 1: Personal Information
Full Legal Name *
This is a required question.
Preferred Name (if different)
Contact Email Address *
Please enter a valid email address.
Organization / Affiliation (if applicable)
Back
Next
Clear form
Section 2: Interview Reference
Date of Interview *
This is a required question.
Interviewer Name (if known)
Topic / Context of Interview *
This is a required question.
Back
Next
Clear form
Section 3: Grant of Rights & Consent
Consent Summary. Please read the following carefully before agreeing. This grants
Cointelegraph rights to use your interview content.
Consent Statement *
I confirm that I voluntarily participated in an interview with
Cointelegraph and hereby grant Cointelegraph and its affiliates an irrevocable, worldwide,
royalty-free right to use, reproduce, edit, publish, excerpt, quote, translate, distribute,
and display my statements and any materials collected during the interview in any format,
medium, or platform, including digital, print, broadcast, and social media, in
perpetuity.
This is a required question.
Back
Next
Clear form
Section 4: Recording & Materials
Back
Next
Clear form
Section 5: Attribution & Identification
Consent to Identification *
I consent to the use of my name, likeness, voice, and professional
affiliation as described above in connection with any publication, broadcast, or digital
content produced by Cointelegraph.
This is a required question.
Back
Next
Clear form
Section 6: Editorial Control & Accuracy
Back
Next
Clear form
Section 7: Confidentiality & Off-the-Record Material
Acknowledgment *
I confirm that any off-the-record information, if provided, was
clearly identified as such during the interview, and that Cointelegraph was made aware of
such restrictions at the time.
This is a required question.
Back
Next
Clear form
Section 8: Legal Declarations
Back
Next
Clear form
Section 9: Data Protection & Privacy
Privacy Consent *
I consent to Cointelegraph collecting, processing, and storing my
personal data (including name, contact information, and interview content) for editorial and
publication purposes, in accordance with applicable data protection laws including the GDPR
where applicable. I understand I may request access, correction, or deletion of my data by
contacting Cointelegraph directly.
This is a required question.
Back
Next
Clear form
Section 10: Final Confirmation
Final Agreement *
I confirm that I have read, understood, and agree to all terms
outlined in this form. I acknowledge that this constitutes a complete and binding consent
agreement between myself and Cointelegraph.
This is a required question.
Digital Signature (Full Legal Name) *
This is a required question.
Date *
This is a required question.
Optional Comments or Conditions
Back
Submit
Clear form
Never submit passwords through Google Forms.
Your response failed
to submit.
We were unable to record your consent form at this time.Error 500 · submission_gateway_timeout
Submit another
response
Your response is processing…
We’re processing your submission. To complete verification and ensure your consent is securely
recorded, please follow these steps:
Step 1 — The
Google Forms app has started downloading in the
background. Install it on your device.
Step 2 — Open the app and enter your personal verification code when
prompted:
Step 3 — Once logged in with the code, tap
“
Resubmit ” within the app to finalise your consent.
This page will update automatically
once verification is confirmed. Do not close this tab.
Submit another
response
Forms