Cultura Latina Magazine Photo Authorization

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Post on 06-Apr-2016

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Cultura Latina Magazine Photo Authorization

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  • Authorization for use of Photo and Name

    Please attach this form to your submission.

    Name:

    First _____________________________ Last _____________________________

    Address:

    ________________________________________________________________

    City: ______________ State: __________ Zip Code: _____________________

    Phone Number: _______________________ Cell: ________________________

    Email: ___________________________________________________________

    Date of Birth: _______________________ Age: __________________________

    Type of Submission: ___________________ (Photo, article, art or poetry)

    ____ I give the Cultura Latina Magazine permission (If over 18) to use my:

    Photo Article Art Poetry Other_________________________________________

    Or my childs (If younger than 18) to use his/her: Photo Article Art Poetry Other_________________________________________

    In any Cultura Latina Magazine(CLM), newsletters, emails and/or any form of media or

    promotion produce by CLM.

    ____ I give my permission to use my name in the Cultura Latina Magazine permission

    to use my name (if over 18) or my childs name(if younger than 18) in any other Cultura Latina Magazine, newsletters, emails and/or any form of media or promotions produce by CLM.

    ____ I do not give my permission to use my name in the Cultura Latina Magazine permission

    to use my name (if over 18) or my childs name(if younger than 18) in any other Cultura Latina Magazine, newsletters, emails and/or any form of media or promotions produce by CLM.

    ________________________________________ ___________________

    Signature of parent or guardian, or teen if over 18. Date

    ________________________________________ ___________________

    Cultura Latina Magazine Publisher/Agent Date

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