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Permission To Use Quote Or Personal Statement
FOR GOOD CONSIDERATION, the undersigned irrevocably authorises (name) and its successors and assigns to use, publish or reprint in whole or in part the following statement, picture, endorsement or quotation:
(Outline or attach marked as exhibit "A").
This authorization shall extend only to a certain publication known as (name), including all new editions, reprints, advertisements, publicity and promotions thereto of said work.
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]