I, the undersigned

Name & surname :

Adress :

In accordance with the provisions relating to the right to the image, I authorize Tom Ratni whose head office is located in France and its technical service providers to take photographic shots, videos or digital recordings during the photo shoot that will take place on the at .

The images may be exploited and used directly by Tom Ratni in any form and media, for an unlimited territory, without time limit, in full or by extracts and in particular: press, book, digital media, exhibition, advertising, public screening, competition, website, social networks.

The beneficiary of the authorization expressly refrains from exploiting the photographs likely to damage privacy or reputation, and from using the photographs, videos or digital recordings hereof, in any harmful medium or exploitation.

I acknowledge that I am fully fulfilled of my rights and I will not be able to claim any remuneration for the exploitation of the rights referred to herein.

I guarantee that neither I, nor, if applicable, the person I represent, is bound by an exclusive contract relating to the use of my image or name.

For any dispute arising from the interpretation or execution hereof, jurisdiction is expressly conferred on the French courts.

Done at , on in two copies.

Read and approved

Signature

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