PIXTA Inc.

IVY East Building 9F, 3-11-11

Shibuya Shibuya-ku
Tokyo 150-0002 Japan
T: +81-3-5774-2692 F: +81-3-5774-2695

PIXTA_201310
MODEL RELEASE

Photographer Information
Name (Print):

Signature:


TEL:
Date Signed(dd/mm/yyyy):
Date of Shooting(dd/mm/yyyy) :
Place of Shooting (Country, State, City)

Description of Shooting

Note (Optional)


For good and valuable consideration, the receipt and legal
sufficiency of which is hereby acknowledged,
I (hereinafter
referred to as the Model) hereby grant to
Photographer and
his or her assigns and those who act with the
Photographers authorization and permission (collectively
hereinafter referred to as the Photographers) the right to
license and use the photos, illustrations, and/or
videos/footage in any and all format, in which my likeliness
is depicted or incorporated (hereinafter referred to as the
Contents) under the terms and conditions as provided
below.
I also hereby warrant that there will be no claim, complaint
or objection from me or from any third party in respect of
any license or use of the Contents as provided herein.

1. I hereby agree that the Contents may be used, re-used,
published, re-published, edited, copied, reproduced,
adapted, altered, worked, distorted, transformed and/or
combined with textual matter and/or other pictures in any
and all media, whether now known or hereafter created, for
any purpose and in any manner whatsoever, including but
not limited to illustrations, graphic designs, art works,
advertisements, promotions, broadcasting, printings,
commercial transactions.
2. I hereby agree that the Contents may be used worldwide.
3. I hereby agree that all rights in and to the Contents
including but not limited to the copyright are and shall
remain the sole property of the Photographers, and that I
am not entitled to additional consideration or monetary
rewards for, or delivery of, advertisements, motion pictures,
printed materials, merchandises or any other products in
which the Contents are used or incorporated.
4. I hereby agree that I will make no further claim for any
reason to the Photographers in respect of any use or usage
of the Contents, for ceasing and desisting such use of the
Contents or for collecting any products incorporating the
Contents.
5. I hereby release, discharge, and agree to hold harmless
the Photographers, from any liability by virtue of any use of
the Contents or any blurring, distortion, alteration, trick,
or combination that is made, or would be made, to the
Contents, whether intentionally or not, upon the shooting,
in the course of processing after the shooting, upon the
publication or any other phase.
6. I hereby agree that this release is irrevocable and
perpetual, and effectively binding upon me, my heirs and
assigns.
7. I agree that my personal information will not be made
publicly available but may only be used directly in relation
to the licensing of the Contents whenever necessary and
may be retained as long as necessary to fulfill such purpose
as provided herein.
8. I represent and warrant that I am of full legal age and
have the full legal capacity to execute this release or that I
have obtained appropriate consent from my parent or
guardian as set forth below.


Model Information
Model's Name (Print)


Date of Birth(dd/mm/yyyy)

Model's (or Parents')* Address:


City: Country:
Zip Code:
TEL

Email

Date Signed(dd/mm/yyyy):
Signature




*If Model is a minor or lacks capacity in the jurisdiction of
residence, his or her parent(s) warrants and represents
that parent(s) is/are the legal guardian of the Model, with
the full legal capacity to consent to execute this release of
all rights in the Contents where Model is depicted or
incorporated. If you are signing in this capacity, please
enter your details above and your name(s) below.

Models Parent(s) or Guardian
Name Print (if applicable):