Date________________

Dear Patron:

It is our library's practice to seek your permission before including your photo when preparing work for external publications or on the Internet.

In order to include your photo in the project described below, we'd like to have your signed permission. Please review the information, sign the form, and return it to the library.

Please sign and return to the library.

I hereby give permission to (library) ____________________________________ my permission to publish my photo for an external publication _________________ (date) on the Internet.

I also understand that I have the option of granting permission for use of my name with the photo.

I choose to:

__ have my name appear

__ not have my name appear

Signature________________________________ Date__________________

Daytime Phone_______________________ Evening Phone________________