Permission To Use Quote Or Personal Statement

FOR GOOD CONSIDERATION, the undersigned irrevocably authorises _____________, and its successors and assigns to use, publish or reprint in whole or in part the following statement, picture, endorsement or quotation:

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

Dated:

Signed:__________________________

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