RELEASE AUTHORIZATION TO REPRODUCE PHYSICAL LIKENESS For good and valuable consideration, the receipt of which from director/producer __________________ is acknowledged, I hereby expressly grant to the said film titled “____________” and its employees, agents, and assigns, the right to photograph me and use my picture, silhouette, and other reproductions of my physical likeness (as the same may appear in any still camera photograph and/or motion picture film), in and in connection with the exhibition, theatrically, on television or otherwise, of any motion pictures in which the same may be used or incorporated, and also in the advertising, exploiting, and/or publicizing of any such motion picture, but not limited to television motion pictures. I further give the said company the right to reproduce in any manner whatsoever any recording made by said company of my voice and all instrumental, musical, or other sound effects produced by me. I hereby certify and represent that I have read the foregoing and fully understand the meaning and effect thereof and, intending to be legally bound, I have here unto set my hand this __________ day of ________, _____. Signature: ____________________________________________ Print Name: ____________________________________________ Address: ____________________________________________ Phone #: _______________ E-mail Address: ______________