PERMISSION TO USE QUOTE OR PERSONAL STATEMENT

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： _

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