REVOKE OF PARENTAL CONSENT FORM
Print this form, fill in the information and fax to AgDirect at (406) 556-0214.
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AgDirect Dear AgDirect: I, the undersigned, CERTIFY UNDER PENALTY OF PERJURY that I am the Parent and/or Legal Guardian of _________________________________ ("Child"). I am REVOKING my consent to AgDirect, as Legal Guardian, for the above-mentioned child. This child is to no longer interact with your web sites, including and without limitation, emailing, and advertising ranches, horses, etc. I have read the Privacy Disclosure and understand that linking to an AgDirect web site is a choice I and/or my child makes, and that it is my responsibility to monitor their linking to and giving information to web pages that access AgDirect databases. I understand that if I change my consent at any time in the future that it is my responsibility to make AgDirect aware of that via the Parental Consent form, complete with signature. |
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 Child: |
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| Date: | |
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| CONTACT INFORMATION | |
Printed Name: |
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| Title & Company: | |
| Street Address: | |
| City and State: | |
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| Telephone: | |
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| SIGNATURE | |
Signature: |
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| Printed Name: | |