Contact Information

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Additional Comments

Training Selection

Kinetix Workbench*

I grant to Werner Electric Supply, its representatives and employees the right to take photographs of me
and my property in connection with the above-identified subject. I authorize Werner Electric Supply, its
assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that
Werner Electric Supply may use such photographs of me with or without my name and for any lawful
purpose, including for example such purposes as publicity, illustration, advertising, and Web content. By
clicking submit, I hereby waive, release from liability, indemnify, and hold harmless Werner Electric Supply
Co., and all of its insurers, shareholders, members, managers, officers, directors, agents, representatives,
contractors and/or employees, from any and all claims, demands, losses, liability, damages or causes of
action in any way arising out of or related to any injury, disability, death, loss or damage to person or
property (whether suffered by me or any third party) resulting from my participation in and/or presence at
the Kinetix Workbench training, to the fullest extent permitted by law.  I KNOWINGLY AND FREELY ASSUME ANY
AND ALL RISKS OF EVERY KIND AND CHARACTER which may occur to me and/or my personal property in
connection with the Kinetix Workbench training.