Authorization and Release

Authorization and Release Form
Date *

Month Day Year
Program Working Title *
Name of the show or ad
Program Type: *

TV Show Commercial Music Video Interview
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 Name Middle Name Last Name
A.K.A
Artist is also known as...
Title: *

Artist Manager Guest Sponsor Organizer
Name of parent or guardian if above named person is not of legal age:
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

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

Authorization and Release Form