The original photographer is an artist in his or her own right. Permission is required to create a new, derivative work from the photo. Please have the original photographer grant his or her permission to create a new work of art.

I, ________________________________________________________________

do hereby give permission for my photograph(s): (title or other identifier)

_____________________________________________________________

to be used by Robert Goldberg to create a digital portrait of:

_____________________________________________________________

I certify that I am the creator of the photograph(s) or the creator's duly assigned representative, empowered to act herein.

I will hold Robert Goldberg harmless for any action, copyright or otherwise, that may ensue from this use of the photographic material.

I understand that the portrait will constitute a new, independent and derivative work of art, and all rights, including right of reproduction, remain with Robert Goldberg, who may reproduce the portrait for the specific client, and for educational or promotional purposes .

Signed this date _____________________________

_____________________________________________________________
Signature

Please print the following information:

_____________________________________________________________
Photographer or owner of photograph

_____________________________________________________________
Address, City, State, Zip

_____________________________________________________________
Phone including area code

_____________________________________________________________
e-mail address

 

Please print this out, have fully executed, and send via US Postal Service to

Robert Goldberg  P.O.Box 300121  Fern Park, FL 32730