Consent / Clearance Form

With reference to the following production:

Produced by: Amina Diwa Saadat

* In consideration of the non-remuneration agreement between myself and Harrow College Media Productions I consent to the interview / contribution given by me to you on ……16…./…12……./……09…. giving over ‘unlimited’ rights to the above named production company. This agreement also allows ‘unlimited’ future copying / broadcasting of the said material without payment.

This agreement enables the above named producer / production company to exploit the performance / interview / contribution, which I hereby give my consent, in any contemporary or future audio-visual media throughout the territories of the United Kingdom and the rest or the World.

Name (Please print): Stuert Poole


Date: 12/12/09

Address:

11 Mary Avenue,
Harrow,
Ha5

Contact telephone number: 07983445321

Signature: