Permission to Use Photograph TO: FULL NAME OF PARTY RECEIVING PERMISSION TO PHOTOGRAPH (the "Photographer") In consideration of the sum of two dollars ($2.00) and for other good and valuable consideration (the receipt of which is hereby acknowledged), the undersigned hereby agrees as follows: 1. Subject to the conditions referred to in paragraph 2 below, the undersigned grants to the Photographer: (a) the right to photograph the undersigned without charge, for the sole, specific purpose of State specific purpose for taking photograph (ie. use in an antiviolence advertising campaign) (the "Purpose"); and (b) a license (the "License") to use any photographs taken of the undersigned (the "Photographs") for the Purpose. 2. The rights granted to the Photographer hereunder under paragraph 1 are conditional upon and subject to the following: (a) The Photographs shall not be used for any purpose other than the Purpose without the prior written consent of the undersigned; (b) The Photographer shall provide the undersigned with proofs of the Photographs prior to using them, and the undersigned shall have the right to approve in writing which, if any, of the Photographs may be used by the Photographer, and the Photographer shall destroy all other Photographs and any negatives, or reproductions thereof; and (c) The Photographer shall not modify, tamper with or otherwise alter any of the images in the Photographs. 3. This agreement shall be binding upon the undersigned and his heirs, executors, administrators and assigns, hereby: Date: Date of Signing of Document ____________________ ___________________________________________ Witness Name of Person Giving Permission to Photograph