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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