You must have JavaScript enabled to use this form. I, hereby grant permission to ClarkDietrich to reproduce any portion of the photo images listed in the below table that have been taken by me: (Photographers full name) for the purpose of SELF USE and or SELF PROMOTION publications which can include but is not limited to, books, cards, calendars, invitations and websites without any more compensation or recognition given to me. Furthermore, I grant creative permission to alter the photograph(s). I do not grant permission to resale or use the photographs in a manner that would exploit or cause malicious representation toward me or my company and associates. Business Information: Name Company Email Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Permission granted for photographs listed below: Date Taken/Picture or Bundle Description Image 1 Image 2 Image 3 Image 4 Image 5 I authorize ClarkDietrich to use and publish photographs and/or video footage of me, or in which I may be included, for editorial trade, advertising and any other purpose and in any manner or medium; and to alter the same without restriction. I understand that I am to receive no compensation for this work. The client shall have complete ownership of the work for an unlimited amount of time. I give the agency and client the right to use my name, likeness and biographical material to publicize the programs and services of the client. I waive the right to inspect or approve the work or the specific uses to which they are applied. By signing below I represent that I am not a party to a contract, agreement or understanding that prevents me from entering into this agreement. Any infringements of this policy may violate federal law. Signature Sign above