MATERIALS RELEASE FORM

[YOUR COMPANY NAME], respectfully requests permission to use

	

which will become part of the television broadcast and/or video program entitled, 	
	
produced by [YOUR COMPANY NAME].  This program will be recorded on video tape for later broadcast, as well as distributed on video.
Full credit would be given to 	
	
at the close of the show in which this video is used.
We sincerely hope that you will grant us the permission requested, and will indicate such by signing and returning this form.  Your prompt and courteous consideration of this request is very much appreciated.

PERMISSION GRANTED THIS [DAY] OF [MONTH], [YEAR]:
 
[NAME OF FIRM OR ORGANIZATION] 

Authorized By:		
Position:	  	
Address:	  	
City, State, Zip:	
Phone Number: (area code)	

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