PICXY.
COM have the right to contract in my own
name. I have read the above
Model Release Form authorization, release and agreement,
prior to its execution, and I am fully
For good and valuable consideration, the familiar with the contents thereof. This
receipt and legal sufficiency of which is release shall be binding upon me and my
hereby acknowledged, I heirs, legal representatives and assigns.
_______________(“Model”) hereby grant
to_________________________________
and PICXY.COM. (collectively, the
Photographer Information
“Photographer”), the Photographer’s
assigns, and those persons acting with the
Name :
Photographer’s authority and permission,
Address:
the right to take and create
photographs/videos and other still and/or
City:
moving images (in all formats) and other
State:
graphical depictions incorporating my
Country:
likeness, in any and all media, whether
Zip/Postal Code:
now known or hereafter created (the
Phone:
“Content”). I hereby agree that all rights in
Email:
and to the Content, including the
Date of Shoot:
copyright, are and shall remain the sole
Signature:
property of the Photographer, free and
clear from any claims by me or anyone
acting on my behalf.
Model Information
The Photographer’s rights include, but are
not limited to, the rights, in perpetuity, to: Name :
Use, re-use, publish, and re-publish the Address:
Content; Alter, modify or otherwise
change the Content in any manner the City:
Photographer desires; Combine the State:
Content with textual matter and/or with Country:
other pictures and/or media; and, Use the Zip/Postal Code:
Content for illustration, promotion, art, Phone:
editorial, advertising, trade, publishing, or Email:
any other purpose whatsoever. I hereby Date of Birth:
release, discharge, and agree to hold Signature:
harmless the Photographer, the Date:
Photographer’s heirs, legal Description of Scene:
representatives and assigns, and all
persons acting under the Photographer’s
authority or those for whom he/she is Visual Reference
acting, from any liability by virtue of any (If Minors, Parental Witness is Accepted)
use of the Content or any changes or Witness:
alterations made there to. I hereby Name :
warrant that I am of full legal age and Signature:
Date: