Photograph, Television, and Radio Release

Job Number
Date
MM slash DD slash YYYY
For valuable consideration, receipt of which is hereby acknowledged, I hereby consent and authorize Primm, Inc., it’s subsidiaries, successors, and assigns, and clients of Primm, Inc., their successors and assigns, to use and reproduce my photograph(s) or likeness(es), video tape recordings or motion pictures taken or recorded on this day and circulate the same. I further release Primm, Inc,, its subsidiaries, successors and assigns, from any and all claims for damages, libel, slander, invasion of the right of privacy, or any other claims based on, arising out of, or connected with the use of said likeness. No representations have been made of me.
Model Name*
Phone*
Email*
Model Signature*
Address*
Street Address Address Line 2 City State ZIP Code
Parent or Guardian Name If Minor
Signature of Parent or Guarding If Minor
Witness By Name
Witnessed By