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Permission To Use Quote Or Personal Statement

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

(Describe and/or attach).

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

Dated:

__________________________

{UNDERSIGNED}