Date: ________________

Topic of interview ("subject"): __________________________________________

Interviewee (the person giving the interview)

Name: _____________________________________

Street: _____________________________________

City: _____________________ State/Zip _____

Interviewer (the person conducting the interview)

Name: _____________________________________

Company: __________________________________

Street: _____________________________________

City: _____________________ State/Zip _____

I, the interviewee, agree to be interviewed and/or recorded by author or publisher or producer about ("subject"). I also agree to allow descriptions of my experiences, as well as my words, photo, audio or video recording, and any other biographical or other information or material that I choose to provide, to be used as part of the work about ("subject").

I retain the right to use any or all of the information and words I provide during this interview for my own purposes as I wish.

It is agreed between us that this release apply equally to any interviewer, publisher, or producer who publishes or produces work that incorporates descriptions of interviewee's experiences or other information or materials from this interview, and is irrevocable.

I, interviewee, release interviewer, author, and publisher from any and all copyright claims relating to the work for any of the uses above, in any and all editions, versions, and media.


Signature: _____________________________

Print Name: ____________________________

Interviewer, author, publisher, or producer:

By: ____________________________________

Print Name: _________________________________