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PERMISSION TO USE QUOTE OR PERSONAL STATEMENT[1]

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PERMISSION TO USE QUOTE OR PERSONAL STATEMENT FOR GOOD CONSIDERATION, the undersigned irrevocably authorizes _, and its successors and assigns to use, publish or reprint in whole or in part the following statement, picture, endorsement or quotation: [Describe or attach] _ This authorization shall extend only to a certain publication known as _, including all new editions, reprints, advertisements, publicity and promotions thereto of said work. Dated: _ _______________________________
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