Download - Cultura Latina Magazine Photo Authorization
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 child’s (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 child’s 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 child’s 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