Lippincott Williams & Wilkins
ARTWORK OR PHOTOGRAPH OF ARTWORK RELEASE ARTIST NAME: ________________________________________________________________________ ARTWORK NAME/ID:__________________________________________________________________I hereby grant permission to the American Society of Addiction Medicine (“ASAM”) to use the artwork identified above and/or photograph of this artwork in ASAM publications and/or multimedia products. Additionally, I grant permission for the use of the artwork and/or photograph of artwork, whether in part or whole, in subsequent editions of the publication and in any other ASAM publications and products, now known or hereafter devised. It is my understanding that this agreement releases ASAM from any legal responsibilities for use of the artwork and/or photograph of the artwork in ASAM publications. I understand that I will not be reimbursed for the use of the artwork, and I expressly warrant that the artwork and/or photography of the artwork is original or that I have the full power to convey all the rights herein conveyed to ASAM. ASAM is permitted, although not obligated, to include my name and biographical information in connection with the artwork and/or photograph of artwork.I am of full age and legally able to enter into this agreement. I have read this release and am fully familiar with its content. Signed: ______________________________________________________________________________ Date: _______________________________________________________________________________ Witness Name: ________________________________________________________________________Sign and Print PleaseArtist Mailing Address: __________________________________________________________________ _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________Email: _______________________________________________________________________________Phone: _______________________________________________________________________________ ................
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