General 2 — The ExtraOrdinary Women Project BN

ExtraOrdinary Women Project Honorees

EOW Honoree Authorization Form (Print and Mail)

EOW Honoree Authorization Form

The ExtraOrdinary Women Project * P.O. Box 923 Bloomington, IL 61702-0923

The Undersigned hereby grants exclusive rights to the Extraordinary Women Project BN (hereinafter, EOW), its officers and legal representatives, to distribute, reproduce and publish my story and legacy, whether in written, audio, electronic, or film/video format, including photographs, without payment to the undersigned or anyone on their behalf, for use in the publication of the EOW Children’s Activity Books for distribution exclusively within the discretion of the EOW. The EOW retains the right to use the obtained information, in whatever form, for use in promotional literature, advertising, or similar content within the exclusive discretion of the EOW.

Name

First Name

Last Name

Birthdate

YYYY

I certify that I am at least eighteen (18) years of age, and have read, understand, and agree to the above information.

YES

Date

YYYY

Name (This signature is binding to the above statements.

First Name

Last Name