To be filled out by the person granting permission to SIL International:

I, ______, hereby grant to SIL International (SIL), voluntarily and without compensation or restriction of any kind, full use of the map, audio recording, or photographic or video image(s) of or by me, or of anyone for whom I have legal responsibility (named below); or use of the quotation(s) listed below (or cited in an added page), of which I am the originator or creator, for any official publication, presentation, exhibit, video, web or other print or digital format, or any other form of publication or distribution now known or hereafter invented. I further grant to SIL International full rights to republish, without time restriction, these recordings, graphics, quotations, or images in official SIL International publications and reports.

  1. Name the source publication(if relevant):______

Name of the SIL publication: ______

  1. Describe the item you givepermission to use,below (add lines, as needed):

Photo(s), title/description of each: ______

Graphic(s), title/description of each: ______

Map(s), title/description of each: ______

Quotation(s), title/description of each:______

Video(s), title/description of each: ______

Audio(s), title/description of each: ______

  1. Please give your address for contact purposes:

Printed name: ______Signature: ______

Address:______

City:______State:______Country: ______

Date signed: ______20____

  1. Write out how you want the attribution (acknowledgment) to be worded:

Please attribute as follows (e.g., “Used with permission,” or “Photo by ______.”): ______

Please do not attribute

  1. If you can be recognized in a photo or other image, or if your name is used in the text of the manuscript, please complete this section giving your Informed Consent/Permission for SIL International to use your name or that image—and describe the item (in section 2,above):

Printed name: ______Signature: ______

Address:______

City:______State:______Country: ______

Date signed: ______20____

  1. If therecognizable personin an image is a minor, as guardian, please complete this section giving yourInformed Consent/Permission to use that image—and describe the image(in section 2, above):

Print the name of the minor:______

Printyour name—and give your relationship to the minor: ______

Sign your name, granting permission: ______

Address:______

City:______State:______Country: ______

Date: ______20______

Person who requests this form for SIL International (typically the author):

SIL Representative:______

For the SIL publication, entitled: ______

SIL International gathers images throughout the world in an effort to tell the story of language-based development for ethnolinguistic minority peoples. SIL appreciates your cooperation and consent in allowing us to use your photo image, graphic, map, video, audio recording, or textual citation in various media. You have our assurance that these images, audio, or quotations will be used only for official purposes and with the respect and consideration to which you are entitled.

SIL International

Global Publishing Services

7500 W. Camp Wisdom Road

Dallas, Texas 75236-5629