350 5th Avenue . 21st Floor . New York .

New York 10118

SHUTTERSTOCK, INC.
Model Release for MINOR Model Information:

For good and valuable consideration, the receipt and Name (Print): ______PRATIWI SAMSULIANA NURFARINDA_____
legal sufficiency of which is hereby acknowledged,
I ___________PRATIWI SAMSULIANA NURFARINDA (“Model”) Address: _____________ ROTAN MULYA, MESUJI RAYA________
hereby grant to ___________________SLAMET MULYADI
City: ___OGAN KOMERING ILIR State: ___SOUTH SUMATRA___
and SHUTTERSTOCK, INC. (collectively, the “Photographer”),
the Photographer’s assigns, and those persons acting with the Photographer’s Country: ____________INDONESIA_ Zip/Postal Code: ____30681__
authority and permission, the right to take and create photographs/videos
and other still and/or moving images, (in all formats) and other Phone: ___+6282278534263 Email: [email protected]_
graphical depictions incorporating my likeness, in any and all media,
Date of Birth: _________________________AUGUST 29th 2002____
whether now known or hereafter created (the “Content”).
Signature of Parent/Guardian (if minor): _________________________
I hereby agree that all rights in and to the Content, including the copyright,
are and shall remain the sole property of the Photographer, free and clear Date: ___________________________________AUGUST 14th 2019__
from any claims by me or anyone acting on my behalf. Description of Scene: __PHOTOSHOOT USING PRAMUKA
CLOTHES_________________________________________________
The Photographer’s rights include, but are not limited to, the rights,
in perpetuity, to:

Use, re-use, publish, and re-publish the Content; Alter, modify or otherwise
change the Content in any manner the Photographer desires; Combine the Model Ethnicity (Optional):
Content with textual matter and/or with other pictures and/or media; and,
Use the Content for illustration, promotion, art, editorial, advertising, trade, _v_ Asian ___ African-American
publishing, or any other purpose whatsoever. ___ Black ___ Caucasian (White)
___ European ___ Hispanic (Latin)
I hereby release, discharge, and agree to hold harmless the Photographer, ___ Middle Eastern ___ Native American
the Photographer’s heirs, legal representatives and assigns, and all
___ Pacific Islander ___ Mixed Race
persons acting under the Photographer’s authority or those for whom he/
she is acting, from any liability by virtue of any use of the Content or any ___ Other: _____________________________________________
changes or alterations made thereto.

Visual Reference
I warrant and represent that I am the father/mother/guardian (circle one) of
(Optional headshot or other reference may be included here.
______________________________NUR KHASANAH, the Model above
Nude imagery requires a driver license)
named. I have read the above authorization, release and agreement,
prior to its execution, and I am fully familiar with the contents thereof.
This release shall be binding upon me and my heirs, legal representatives
and assigns.

Photographer Information:
Name (Print): ______________________SLAMET MULYADI_

Address: __SUMBU SARI, MESUJI RAYA, OGAN KOMERING ILIR

City: __OGAN KOMERING ILIR State: __SOUTH SUMATRA

Phone: ______+6285315845678 Email: [email protected] Name (Print): _____________________DELFI NATASYA_____

Date of Shoot: __AUGUST 14th 2019___ Medium: v Still Video Signature: ___________________________________________________
Signature: _____________________________________________________ Date: ________________________________AUGUST 14th 2019___
Rev. 10/2012