PERMISSION TO USE QUOTE, PHOTOGRAPH
OR PERSONAL STATEMENT

FOR GOOD AND VALUABLE CONSIDERATION, the receipt and sufficiency of which

being hereby acknowledged, the undersigned irrevocably authorizes ____________________, and its successors and assigns, to use, publish or reprint in whole or in part the following statement, picture, endorsement or quotation:

_________________________________________________

_________________________________________________

_________________________________________________

This authorization shall extend only to a certain publication known as______________________, including all further or new editions, reprints, advertisements, publicity and/or promotions thereof.

Dated this______ day of_______________, 200(x).