Permission to Use Quote or Personal Statement

PERMISSION TO USE QUOTE
OR PERSONAL STATEMENT

FOR GOOD CONSIDERATION, 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: (Describe or attach)
_

This authorization shall extend only to a certain
publication known as _, including all new editions, reprints,
advertisements, publicity and promotions thereto of said work.

Dated: _
_____________________________

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