Fast Agency PERMISSION FORM The Undersigned hereby grant(s) permission to Steve Monas (hereinafter referred to as the “Author”), located at 3089C Clairemont Dr., Suite 163. San Diego, CA 92117, and to Author's successors and assigns, to use the material specified in this Permission Form in the book titled Chemistry and Numbers, to be published by BookSurge LLC ; 5341 Dorchester Road, Suite 16, Charleston, SC 29418.. This permission is for the following material: Nature of material: Writing samples, Stories, Essay, photographic images or artwork, drawings, renderings or advertisements. * Source ( Story Title ): Description of Material: This material may be used in the Author's book and in any future revisions, editions, and electronic versions thereof, including non - exclusive world rights in all languages. It is understood that the grant of this permission shall in no way restrict republication of the material by the Undersigned or others authorized by the Undersigned. If specified here, the materials shall be accompanied by a copyright notice as follows and a credit line as follows Other provisions, if any: If specified here, the requested rights are not controlled in their entirety by the Undersigned and the following owners must be contacted: *Print Name (Talent) *Email address *Digital Signature (Talent) *Date [MM/DD/YY] *Address: *State: *Zip Code: Paypal Email Address: Print Name (Fast Agent) Authorized Signature (Fast Agent) Date [MM/DD/YY]
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