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KTOP Cable Channel 10 Release Form Production Title ________________________________________ Production Date ________________________________________ 1) I, the undersigned, hereby authorize KTOP-TV, its employees or agents, to photograph me, take motion pictures of me, take videotapes of me, and /or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions). 2) I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by KTOP-TV (I understand that I may be identifiable from such photographic or electronic reproductions.) Agreed and accepted by: ____________________________________________________ Print Name ____________________________________________________ Title ____________________________________________________ Address ____________________________________________________ City, State, Zip ____________________________________________________ Phone ____________________________________________________ Signature & Date I am signing this form as an individual yes no I sign this form as a representative of a group yes no Name of the group _____________________________________________ |
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