8/12/2019 Consent 2014 FINAL

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CARLOS PALANCA MEMORIAL AWARDS FOR LITERATURE Year: 2014

c/o CPMA Research Facility6F Unit 603 Park Trade Center

1716 Investment Drive, Madrigal Business Park, Ayala Alabang, Muntinlupa City 1770

CONSENT (ADAPTED WORK/S)

(This form must be notarized.)

1. FOR ORIGINAL WORKS

I represent and warrant that I have written or created _______________________________________ (the Original Work(s)) and that I am the absolute owner of the

copyright(s) and all other intellectual property rights pertaining to the said Original Work(s). I hereby give my consent to ______________________________________ (the

Contestant) to adapt the Original Work(s) and enter the work(s) listed below as adapted (the Adapted Work(s)) in the Carlos Palanca Memorial Awards for Literature contest

(the Contest) for the current year.

2. FOR PUBLISHED/PRODUCED WORKS

I represent and warrant that I am the publisher/producer of the work(s) listed below as published/produced(the Published/Produced Work(s)). I hereby give my

consent to the Contestant to enter the Published/Produced Work(s) in the Contest for the current year.

TITLE DIVISION CATEGORY PUBLISHED/PRODUCED WORKS

Indicate publication, publisher, and publication date/

venue of production, producer, and production date

1.

2.

3.

4.

5.

I declare that I have read the rules of the contest (the Rules), and hereby accept the said Rules and the concurrent and non-exclusive right of the Carlos Palanca

Foundation (the Sponsor)to exercise the full copyright and all other intellectual property rights granted to the author and the authors assignees , with respect to any winningwork(s), including all of the Contestants previous Palanca Award prize winning work(s) if any, (collectively, the Work(s)), to the extent permitted under existing laws

applicable at the time of exercise. The grant and assignment also extends to all forms of storage, transmission, dissemination, and communication, presently existing and/or

subsequently created. To the extent permitted by law, the grant and assignment of rights shall be worldwide, continuous, and may be exercised by the Sponsor for the maximumtime allowed by applicable law. The prize money which may be awarded to the Contestant for any of the Work(s) shall constitute full payment of the foregoing rights assigned to

the Sponsor, and shall be in lieu of any royalties or other compensation tome and to the Contestant.

I hereby hold the Carlos Palanca Foundation, its directors, officers, employees, consultants, and authorized representatives, free, harmless, and exempt, from any and

all liability in the event that any of the Adapted/Published/Produced Work(s) infringe my intellectual property rights with respect to the Original/Published/Produced Work(s).

______________________________________________________

Printed Name of Original Author Signature

______________________________________________________

Printed Name of Publisher/Producer Signature

I hereby undertake to indemnify the Carlos Palanca Foundation, its directors, officers, employees, consultants, and authorized representatives, for any and all damages,

liabilities, claims, losses, and fees, including reasonable attorneys fees, in the event that the Adapted/Published/Produced Work(s) infringe the intellectual property rights of

another.

______________________________________________________ ______________________________________________

Printed Name of Contestant Signature

(NOTE: If the participant is a minor, the following should be accomplished by the parent or legal guardian.)

PARENTAL CONSENT

(For contestants who are minors.)

I, the undersigned parent and/or legal guardian of _______________________________________, hereby execute this Consent on his/her behalf.

_________________________________

Printed Name and Signature

(Parent/Legal Guardian)

ACKNOWLEDGMENT

Republic of the Philippines)) S.S.

BEFORE ME, this ____ day of _____________________, in ____________________, Philippines, personally appeared:

Name Government-issued Evidence of Identity Date/Place of Issue/Validity Period

known to me and to me known to be the same person/s who executed the foregoing instrument and who acknowledged to me that the same is his/her/theirvoluntary and free act and deed.

Doc. No. ____;

Page No. ____;

Book No. ____;Series of 201_.