Attachment A

Official Submission and
Release Form

 

Name: Phone:
Address: City:
State: Zip: Daytime Phone:
Date(s): this activity or service occured:

I attest that the photograph and story submitted with this form are my original work. I understand and agree that these materials will become the property of the Department of Labor and will not be returned. I have attached the required Photo Release Forms for all identifiable individuals within the submitted photos.

I hereby irrevocably authorize the Department of Labor to edit, alter, copy, exhibit, publish, or distribute this photo and accompanying story for purposes of publicizing the Department of Labor’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my work appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.

I hereby hold harmless and release and forever discharge the Department of Labor from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Signed Date