Please read this permission form, and if you agree, type in your responses and proceed to the questions.

Marcia Stein (“Author") has informed me that she is researching, writing, and publishing one or more books and related works on the subjects of life, love and work (collectively the “Work").

I agree to provide information and possibly other materials to be used in connection with the Work, including my personal experiences, recollections, incidents, remarks, characters, dialogue, actions, scenes, situations, and information, as well as any documents that I may give to Author ("Interview Materials"). I understand that not all entries will be included and they may be edited for clarification.

I consent to the recording of my statements and grant to Author and Author’s assigns, licensees and successors the right to copy, reproduce, and use all or a portion of the statements (“Interview”) for all purposes, including advertising, packaging, or promotional materials for the Work, in any and all editions, versions, and media, in perpetuity and throughout the world in any manner that the Author deems appropriate.  I hereby consent to all such derivative uses, including the exhibition and publication in any and all media, now known or hereafter discovered throughout the world in perpetuity.  

I grant the right to use my relayed experience and biographical data in connection with all uses of the data. I have the option of using a pseudonym {alias or assumed name} for published written materials.  Pseudonym will be assigned by publisher to avoid duplication in materials.  I waive the right to inspect or approve any use of my submission.

I understand and acknowledge that Author will be the sole owner of all copyright and other rights in and to the Work.  In order to enable Author to develop the Work in any manner that Author may deem best, I hereby release Author and Author’s assigns, licensees and successors from any claims that may arise regarding the use of the material including but not limited to any claims of defamation, slander, libel, invasion of privacy, or infringement of moral rights, rights of publicity, copyright or otherwise. I acknowledge that I have no ownership rights in the Work.  Author is not obligated to utilize the rights granted in this Agreement.

I acknowledge and agree that I am not entitled to receive any form of payment from Author and/or her licensees, successors, and assigns.  I have read and understood this agreement and have full right, power and authority to execute this agreement and I am over the age of twenty-one. This Agreement expresses the complete understanding of the parties.