Permission To Use Quote, Photograph Or Personal

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_______________, 201(x).


_______________________    __________________________




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