Fill and Sign the Use Likeness Form

Grant of Right to Use Photographic Likeness for Advertising Purposes I, the undersigned ____________________ (Name of Grantor) , of ________________ ____________________________________________ (street address, city, state, zip code) , in consideration of $____________, the receipt and sufficiency of which is hereby acknowledged, hereby grants to _____________________ (Name of Grantee) , a corporation organized and existing under the laws of the state of _______________, with its principal office located at ____________________________________________________________________ (street address, city, state, zip code) , the right to use and publish for advertising purposes photographic portraits or photographic likenesses or pictures of me. I agree that I may be included in the portraits or photographic likenesses or pictures in whole or in part, in composite or distorted form, in conjunction with my own or a fictitious name, or reproductions of the same, or in color or otherwise, made through any medium. The portraits or pictures are to be taken at the place of business of ___________________ (Name of Photographer) , the Photographer , of __________________________________________________________________________ (street address, city, state, zip code) . I hereby waive any right that I may have to inspect or approve the finished product or the advertising or other copy that may be used in connection with the product or the use to which it may be applied. I hereby release and discharge the Photographer and Grantee, their successors and assigns and all persons acting under their permission or authority, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise, that may occur or be produced in the taking of the pictures, or in any processing tending toward the completion of the finished product, unless it can be shown that they and the publication of them were maliciously caused. Witness my signature this _____ day of _________________, 20_____. _____________________________ Printed Name of Grantor _____________________________ Signature of Grantor