The Undersigned hereby grant(s) permission to ________________________________________________ (hereinafter referred to as the "Photographer"), located at _______________________________________________________________, and to the Photographer’s successors and assigns, to use the material specified in this Permission Form for the following book, product, or use _________________________________________________________________________________________ for use by the following publisher or client __________________________________________________________________________________________________.

This permission is for the following material:

Nature of material __________________________________________________________________________________________________

Source__________________________________________________________________________________________________________

Exact description of material, including page numbers____________________________________________________________________

                      If published, date of publication ____________________________

                      Publisher _____________________________________________

                      Author(s) _____________________________________________

This material may be used in the Photographer’s book, product, or use named above and in any future revisions, derivations, editions, or electronic versions thereof, including nonexclusive world rights in all languages.

It is understood that the grant of this permission shall in no way restrict republication of the material by the Undersigned or others authorized by the Undersigned.

If specified here, the material shall be accompanied on publication by a copyright notice as follows________________________ ________________________________________________________________________________________________________________ and a credit line as follows ___________________________________________________________________________________________.

Other provisions, if any: _____________________________________________________________________________________________

If specified here, the requested rights are not controlled in their entirety by the Undersigned and the following owners must be contacted:________________________________________________________________________________________________________ ________________________________________________________________________________________________________________

One copy of this Permission Form shall be returned to the Photographer and one copy shall be retained by the Undersigned.

___________________________________________________       ____________________________

             Authorized Signatory                                  Date

___________________________________________________       ____________________________