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Case Study Consent
Marketing Agency Client Success Story Case Study Consent & Publication Authorization Form
Blanc theme
formbuilder.ai/f/marketing-agency-client-success-story-case-study-consent-publication-authorization-form
Marketing Agency Client Success Story Case Study Consent & Publication Authorization Form
Client Contact Name
· · ·
Job Title / Role
· · ·
Company / Organization Name
· · ·
Submit
4
Pages
25
Questions
~8min
To complete
Free
No credit card needed
Field types
Short Text ×4
Single Choice ×4
Dropdown ×3
Long Text ×3
Email
Phone
Website URL
daterange
Multiple Choice
File Upload
Yes / No
termsandconditions
Signature
Date
Questions in this template
Free templateThe exact questions included — customize any of them to fit your needs.
Page 1
Client & Company Information
8 questions
Client & Company Details
1
Client Contact Name
*
Short Text
2
Job Title / Role
*
Short Text
3
Company / Organization Name
*
Short Text
4
Business Email Address
*
Email
5
Phone Number
Phone
6
Company Website
Website URL
7
Industry
*
Dropdown
8
Company Size
*
Dropdown
Page 2
Project & Results Overview
6 questions
Campaign / Project Details
1
Project or Campaign Name
*
Short Text
2
Service Category
*
Dropdown
3
Project Duration
*
daterange
4
Please briefly describe the challenge or goal your company faced before working with us
*
Long Text
5
Describe the key results, outcomes, or metrics achieved through our collaboration
*
Long Text
6
How would you rate the overall success of the project?
*
Page 3
Publication Authorization & Permissions
6 questions
Content Usage & Publication Consent
Please review and authorize how we may use your company's success story. We respect your privacy and will only use approved content in the formats you consent to below.
1
I authorize the use of this case study in the following formats
*
Multiple Choice
2
May we use your company name and logo in the published case study?
*
Single Choice
3
May we include a direct quote attributed to you by name and title?
*
Single Choice
4
May we use specific performance metrics and data points in the case study?
*
Single Choice
5
Upload your company logo for case study use (optional)
File Upload
6
Would you be willing to participate in a short video testimonial in the future?
Yes / No
Page 4
Review, Legal Consent & Signature
5 questions
Final Review & Authorization
By signing below, you confirm that you are authorized to grant permission on behalf of your organization for the use of the information and materials described in this form. You understand that you may request revisions or withdrawal of the case study by contacting us in writing.
1
Would you like to review and approve the final case study before publication?
*
Single Choice
2
Any additional notes, restrictions, or special requests regarding publication?
Long Text
3
I confirm that I am authorized to represent my organization and consent to the use of the information provided in this form for case study and marketing purposes as outlined above.
*
termsandconditions
4
Authorized Signature
*
Signature
5
Date of Authorization
*
Date
How to use this template
Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.
- Ready-to-use structure — pre-configured fields out of the box
- Applied "Blanc" theme — fonts, colors, and layout already set
- Mobile-responsive — works on every device without extra configuration
- Fully editable with drag-and-drop — change anything in seconds
- Free to use on any plan, no credit card required
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