I, _________________________________(PRINT NAME), BEING A SINGLE ADULT OF AT
LEAST 21 YEARS OF AGE AND AN ACTIVE HOLLYWOOD IMAGE AGENCY TALENT IN
GOOD STANDING WITH THE HOLLYWOOD IMAGE AGENCY, REQUEST A FREE 1-YEAR
BASIC MEMBERSHIEP INTO THE HOLLYWOOD IMAGE MODEL & TALENT AGENCY
SINGLES CLUB. I GIVE THE HOLLYWOOD IMAGE AGENCY FULL PERMISSION TO USE
MY IMAGE FOR PROMOTIONAL PURPOSES AS THE AGENCY DEEMS APPROPRIATE
WITHOUT FURTHER CLAIM.

TALENT SIGNATURE________________________________DATE______________________

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