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: _

_______________________________