Authorization to reproduce Physical Likeness
For good and valuable consideration, the receipt of which from
Patriot's Auto Outfitters
is acknowledged. I hereby expressly grant to Patriot's Auto
Outfitters and to its employees, agents, and assigns, the right to
photograph me and use my picture, silhouette, and other
reproductions of physical likeness (as the same may appear in any
still camera photograph and/or motion picture film), in and in
connection with the exhibition, theatrically, on television or
otherwise, of any motion pictures in which the same may be used or
incorporated, and also in the advertising, exploiting and/or
publicizing of any such motion picture, but not limited to
television or theatrical motion pictures. I further give the said
company the right to reproduce in any manner whatsoever any
recordation made by said company of my voice and all instrumental,
musical, or other sound effects produced by me.
I hereby certify and represent that I am 18 years of age or older
and that my birth date is ___/___/___.
I hereby certify and represent that I have read the foregoing and
fully understand the meaning and effect thereof and, intending to be
legally bound, I have hereunto set my hand
this_____ day of ______________ , 20_____.
City_________ State____ Zip_______
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