Fill and Sign the Permission to Use Interviews for Publication Form

Permission to Use Interviews for P ublication I, the undersigned,       , hereinafter called the Releasor, (Name of Releasor) understand that       , hereinafter called the Author, is (Name of Author) preparing, writing, and will publish a work on the subject of       , ( describe subject) which is currently titled       , hereinafter called the Work. (Title of Publication) In order to assist the Author in the preparation of the Work, I have agreed to be interviewed and to provide information and other materials to be used in connection with the Work, including my personal experiences, remarks, and recollections as well as any photographs and documents that I may choose to give to the Author (the Interview Materials ). I hereby grant and assign to the Author and his/her licensees, successors, and assigns the follow - ing rights in connection with the Interview Materials for use as part of the Work or any advertising, packaging, or promotional materials for the Work, in any and all editions, versions, and media, in perpetuity and throughout the world: 1. The right to quote or paraphrase all or any portion of the Interview Materials, and to generally use and publish the Interview Materials, including my experiences, recollections, incidents, re marks, dialogue, actions, and information, as well as any photographs and documents that I may give to the Author. 2. The right to use my name, image, and biographical data. 3. The right to develop, produce, distribute, advertise, promote, or otherwise exploit the Work as a book or any other Work in any manner that the Author or his/her assigns deem appropriate. I un - derstand and acknowledge that the Author or his/her assigns will be the sole owner of all copyright and other rights in and to the Work. 4. In order to enable the Author to develop the Work in any manner that the Author may deem best, I hereby release and discharge the Author and his/her licensees, successors, and assigns, from any and all claims, demands, or causes of action that I may have against them by reason of anything contained in the Work, or any of the above uses, including any claims based on the right of privacy, the right of publicity, copyright, libel, defamation, or any other right. 5. In consideration of the foregoing, the Author has agreed to provide me with one free copy of the Work in its first edition upon publication. I acknowledge and agree that I am not entitled to receive any other form of payment from the Author and/or his/her licensees, successors, and assigns. WITNESS my signature as of this the ____ day of ___________, 20____. Witness Signature of Releasor             Print or Type Name Print or Type Name Permission to Use Interviews for Publication Page 1 of 1