Honor Wellness Center

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment (check one): *

I understand there shall be no payment for this release.

I understand there shall be a payment for this release in the amount of:

Royalties (check one): *

I understand that no royalty, fee, or other compensations shall become payable to me by reason of such use.

I understand that there shall be royalties for the photograph(s) used in the amount of:

Revocation (check one): *

I understand that with my authorization below the photograph(s) may never be revoked.

I understand that I may revoke this authorization at any time by notifying the Releasee in writing. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date *

MM

DD

YYYY