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IMAGE PERMISSION

NAME:

ADDRESS:

EMAIL:

PHONE:

We are writing a book to be published on the subject of Tattoos for a work tentatively
entitled Dealbreakers (the “Work”) to be published by Warner Books, Inc.

We request permission to include in the Work a photograph of your tattoo; described as:

Will you please grant permission to me and my publishers and their affiliates, licensees
and assigns for the use of this material in the Work in any and all editions, in all
languages, in whole or in part, throughout the world, in all media now known or hereafter
devised, including advertising and promotion of the Work?

Please sign below to indicate your agreement.

Thanks,
Aviva & Gunther & co.

In consideration of my desire to assist you with respect to the Work, which I believe will
be of benefit to the public, I hereby grant you and the Publisher the permission
requested above. I warrant and represent that I am the owner of the rights granted
herein and that the selected material does not infringe upon the copyright or any other
rights of anyone.

______________________________________
[GRANTOR]
Date:

(Optional) Please include the following credit line in the Work:

_____________________________________________________________________
Form of Copyright Acknowledgment/Credit line