Model Release Form
Victoria Pavlov, LLC
300 State Street, Suite 218, New London, CT 06320
www.pavlovphotography.com | victoria@pavlovphotography.com | 860-710-8663
For Consideration herein acknowledged as received, and by signing this release form, I give Victoria Pavlov my permission to license the Content and to use the Content in any Media for any purpose (except pornographic or defamatory) which may include advertising, portfolio, promotion, online, print marketing and packaging for any product or service. I agree that the Content may be combined with other images, text, audio, and graphics audio-visual works; and may be cropped, modified and altered used for photo manipulation, tutorials. I agree and acknowledge that I have agreed to publication of my ethnicity as mentioned below, but understand that other ethnicities may be associated with me by Victoria Pavlov and / or Assigns for descriptive purposes.
I agree that I have no rights to the Content, and all rights to the Content belong to the Victoria Pavlov and Assigns. I acknowledge and agree that I have no further right to additional consideration or accounting, and that I will make no further claim for any reason to Victoria Pavlov or Assigns. I acknowledge and agree that this release is binding upon my heirs and assigns. I agree that this release is irrevocable, worldwide and perpetual, and will be governed by the laws (excluding the law of conflicts) of the country/state from the following list that is nearest to the address of the Model (or Parent*) given opposite: England and New York.
It is agreed that my personal information will not be made publicly available but will only be used directly in relation to the licensing of the Content where necessary (e.g. to defend claims) and may be retained as long as needed to fulfill this purpose, including by being shared with sub-licensees / assignees of the Victoria Pavlov and transferred to countries with differing data protection and privacy laws where it may be stored, accessed and used. I represent and warrant that I am at least 18 years of age and have the full legal capacity to execute this release.
Victoria Pavlov Information
Name Victoria Pavlov
Signature ___________________________________________________
Date signed (DD/MM/YEAR) _______________________________________
Shoot Date __________________________________________________
Shoot Country & Region/State __________________________________
Shoot Description/Ref. _________________________________________
Model Information
Name (print) _____________________________________________________
Date of Birth (DD/MM/YEAR) ___________________________________________
Gender: male female
Model (or Parent*) Information
Residence Address _______________________________________________
________________________________________________________________
City __________________________________ State/Province _____________
Country _____________________________ Zip/Postal Code _____________
Phone _______________________ Email _____________________________
Signature _______________________________________________________
Date signed (DD/MM/YEAR) ___________________________________________
Parent Name:___________________________________________________
Witness (NOTE: All persons signing and witnessing must be of legal age and
capacity in the area in which this Release is signed. A person cannot witness their
own release)
Name (print) _____________________________________________________
Signature _______________________________________________________
Date ___________________________________________________________
*** I require this document to be signed prior to the date of our Photo shoot. If under any circumstances, you will be unable to print out the form, please be prepared to sign it upon your arrival at the location.
| 
