Attachment 4 Image Release M0026320R1001.doc

(MARINE/DoD CIVILIAN RELEASE) Print Full Name of Person

Email Address

ATTACH PHOTO HERE

(Optional)

Social Security # (last 4 digits only)

MOS/Government Employee Position

Current Rank/Grade

Current OIC/Supervisor

Today’s Date

PHOTOGRAPHY/IMAGE RELEASE

In connection with my appearance in still photography, audio and/or video materials, or any other item that I provided (“Content”) being generated, created, delivered or produced by [Name of Contractor] under a contract [contract number] with, and for the benefit of, the United States Marine Corps;

For valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby consent and agree to the production, reproduction, and use by [Name of Contractor] for the United States Marine Corps (“Marine Corps”), and their successors and assigns, of such Content containing my likeness/photograph, name, voice, and/or statements relating to the [TITLE OF WORK]in whole or in part (including any edits, versions, variations, compilations, or modifications of any type, of the Content (singularly the “Content,” or collectively the Content plus any edits, versions, or etc., are hereinafter referred to as the “Contents”) in any and all media now existing or hereinafter invented (including without limitation any and all print, television or radio broadcast, Internet or Intranet, training or recruitment films, and/or any publicity materials for any Marine Corps purpose, and/or for any other use of the Content (or Contents) by the Marine Corps in perpetuity worldwide on or through any distribution medium or in or through any media (including releases sent to the media requesting the Content (or Contents). I further confirm that no further approval shall be required from me (or compensation to me) for any use by the Marine Corps of the Content (or Contents) pursuant to this release.

[Name of Contractor], through the undersigned company representative, hereby confirms that the Marine Corps is or will be the absolute owners of the Content (or Contents) (and all rights therein, including the copyright) produced pursuant to this Release, and the Marine Corps has, or will own, or has, or will obtain, an irrevocable, paid-up, world-wide license to the Content (and Contents) that provides the Marine Corps with the rights to use, modify, reproduce, perform, display, release, and/or disclose such Content (or Contents) in whole or in part, in any manner, and for any purpose whatsoever, and to have or authorize others to do so.

I hereby certify that I am at least eighteen (18) years of age, have the full right to contract in my own name with respect to the matters stated above, that any statements that I made relating to the United States Marine Corps in the Content (or Contents) are my own statements and accurately reflect my own opinions and that I have no conflicting commitments that would cause me to be unable to enter into and grant the rights specified by this Release, which I hereby make binding on my heirs, next of kin, and personal representatives.

Signature

Date

The undersigned Production Company Representative hereby confirms that he/she is authorized to enter into this Release and shall assign all rights, title and interest in the Content (and Contents) that he/she created, generated or provided for this effort.

Title of Work: [TITLE OF WORK] Production Company: [Name of Contractor] Production Company Representative: ___________________________________________________________________________ Printed Name

Signature

Phone No:

Date