Either mail this form with your photos to our corporate headquarters or send this form and photos via email to: photos@twinsmagazine.com

TWINS™ Magazine
Double Takes Photo Submission
Attn: Art Director
PO Box 271924
Fort Collins, CO 80527-1924 USA

-- RELEASE -- AUTHORIZATION TO REPRODUCE PHYSICAL LIKENESS

For good and valuable consideration, I hereby expressly grant all rights to TWINS™ Magazine, and its employees, agents, and assigns to use the picture(s), silhouette(s), or other reproductions of the physical likeness(es) of the following individuals:

Twin Type [ ] Identical [ ] Fraternal [ ] Unknown

Date of Birth _______________________________________ Age in Photo ___________________

Names of persons in photo __________________________________________________________

(Check one or both options)
[  ] in connection with the TWINS™ Magazine web site at www.twinsmagazine.com with no identification of family name or location of residence

[  ] in connection with TWINS™ Magazine, its advertising, promotions, books, reprints, or other materials published by TWINS™Magazine, in print or electronically, now or at any time in the future.

I attest that the title and rights to this/these photograph(s), image(s), reproduction(s), and/or digital likeness(es) are mine to assign on behalf of myself and/or the above mentioned individuals.

I certify and represent that I have read this entire agreement and fully understand its meaning, and I agree to be legally bound by the agreement as presented on the day and year noted below:

______________________________________________, 20_____.
(month and day)


___________________________________________________________________________________
Name (Please print entire name, then sign below)


___________________________________________________________________________________
Signature


___________________________________________________________________________________
Relationship to subjects


___________________________________________________________________________________
Address


___________________________________________________________________________________
City, State, Zip


___________________________________________________________________________________
Email address


_______________________________________________________________
Phone number      [  ] Home    [  ] Work    [  ] Cell