Publication Permission Form:

This form may be completed and e-mailed to a given publication for immediate use. However, if you use this on-line form, it is in trust that you will be forwarding a SIGNED form to the publication to be placed on file for both their and your own protection.

I, _________________, do hereby grant permission for

the ________________________ (type of item)

entitled: ___________________________________

to be used as follows (check all that apply, complete blanks where necessary):

___ One-time publication in an issue of: _____________________________

___ or: publication of that publication for no more than _____ times (separate issues).

___ Performance at the event called ______________________________

___ Posting on Web Page called: ___________________________ managed by:__________________________________

In the case of web publication, I recognize that persons unknown may link to this site or may use my work without my permission. I shall hold the above web page owner harmless from such activity if proper notice appears on the above webpage, and I am immediately notified when the link or use is discovered.

I retain all copyright in my work (This does not include copyrights held by others of items that are included in my work such as characters or specific situations) and may grant permission to any other publication or entity to use my work unless otherwise stated on this form.

Any publication of this work must be accompanied by the following information to assure that the author's or artist's rights are upheld. (This usually includes the date of original creation or publication and the creator's name. May also include the webpage address of the original file):

________________________________________________________________ ________________________________________________________________

Date:

Signature: (signature must be completed on a written form and sent to the publication for this to be valid) Address:

_______________________________________________