In consideration of my engagement as a model, and for other good and valuable consideration herein acknowledged as received, upon the terms hereinafter stated, I hereby grant __Robert E Titus Jr__, his legal representatives and assigns, those for whom _____Robert E Titus Jr___is acting, and those acting with his authority and permission, the absolute right and permission to copyright and use, re-use and publish, and republish photographic portraits or pictures of me or in which I may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, from time to time, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise made through any media at his studios or elsewhere for art, advertising, trade, or any other purpose whatsoever

I also consent to the use of any printed or electronic matter in conjunction therewith.

I hereby waive any right that I may have to inspect or approve the finished product or products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied.

I hereby release, discharge and agree to save harmless _Robert E. Titus Jr___, his legal representatives or assigns, and all persons acting under his permission or authority or those for whom he is acting, 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 said picture or in any subsequent processing thereof, as well as any publication thereof even though it may subject me to ridicule, scandal, reproach, scorn and indignity.

I hereby warrant that I am of legal age and have every right to contract in my own name in the above regard. I state further that I have read the above authorization, release and agreement, prior to its execution, and that I am fully familiar with the contents thereof.

Dated:_________________________ On this date I am _____years of age.

Model's Signature:_________________________

Driver's License State, #_____________________

Name (printed):____________________________

Address:_________________________________

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