Image Consent Form

The information that you supply in this form will be entered into a secure filing system and will
only be accessed by authorized persons of the Department of Information and Communications
Technology. The information will be retained by the Department and will only be used for the
purpose of (a) processing the submission of entry for the Tech4ED Photo Contest and (b)
authorize the use of images for future use by the Department. By supplying such information, you
consent to the Department storing the information for the stated purposes.

I. Applicant Information

Name:

Office:
Address:
Position:
Email Address:
Contact Number:

II. Subject Information

Name:

Address:

Email:

Contact Number:

AUTHORITY TO USE IMAGES:

I hereby authorize the Department of Information and Communications Technology to use any
photographic image produced for the contest in any format taken by me for the purposes of the
department’s use of the image in any of its advertising, promotional or other material including
social media.

I acknowledge that:

• the DICT may use the images from time to time and will be kept as long as they are
relevant until such time the DICT seems fit to destroy;
 • any use by the DICT of my images will be without payment to me and does not require
any further consent by me;

• all intellectual property and any other rights to or in the images will be co-owned by the
DICT;

• to necessary extent, I hereby assign all existing and future rights in the images to the DICT;
and

• this deed does not create or alter any existing employment relationship between me and
DICT.

I certify that the information given above is correct to the best of my knowledge and belief.

_____________________________________________
Signature over Printed Name of Applicant

_____________________________________________
Signature over Printed Name of Subject