Authorization and Release

Authorization and Release Form
Date*

MonthDayYear
Program Working Title*
Name of the show or ad
Program Type:*

TV ShowCommercialMusic VideoInterview
For the opportunity to participate in the above named filming/recording/program, I hereby grant to OWL Media Network, LLC cable, internet, radio producer, permission to record for later transmission my likeness and /or voice as a part of the above named television, radio, satellite and/or cable access programs for any lawful purpose, at any time.
Full Name*

First NameMiddle NameLast Name
A.K.A
Artist is also known as...
Title:*

ArtistManagerGuestSponsorOrganizer
Name of parent or guardian if above named person is not of legal age:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
OFFICE USE ONLY
Should be Empty:

Authorization and Release Form