Entry No.

(to be accomplished by
CPF staff)
Year: 2014
CARLOS PALANCA MEMORIAL AWARDS FOR LITERATURE
OFFICIAL ENTRY FORM AND GRANT/ASSIGNMENT OF RIGHTS
(This or! !"st #$ not%ri&$'.(


AUTHOR)S NAME *
D%t$ o +irth (DD/MM/Y$%r( P,%-$ o +irth A.$ G$n'$r
M F
Ci/i, St%t"s
CONTACT INFORMATION
HOM !O"#$%&'()''
*++"'' :
,*)+,() :
MO%(, )O- :
F*. )O- :
M*(, :
For first/time participa0ts1 please i0dicate ho2 yo3 lear0ed of the Pala0ca *2ards:
A U T H O R I 0 A T I O N
( am hereby e0teri04 the e0closed 2or5(s) (the Wor1(s() listed belo2 i0 the Carlos Pala0ca Memorial *2ards for ,iterat3re co0test (the P%,%n-% A2%r's) for the c3rre0t
co0test year- ( represe0t a0d 2arra0t that ( ha6e 2ritte0 or created the said !or5(s) a0d that ( am the absol3te o20er of the copyri4ht(s) a0d other i0tellect3al property ri4hts pertai0i04 to
the said !or5(s)-
TITLE DI3ISION CATEGORY PU+LISHED/PRODUCED WOR4S
(0dicate p3blicatio01 p3blisher1 a0d p3blicatio0 date$
6e03e of prod3ctio01 prod3cer1 a0d prod3ctio0 date
1-
2-
7-
4-
8-
In th$ $/$nt th%t %ny $ntry o !in$ is %2%r'$' % 5ri&$6 I %"thori&$ th$ S5onsor to 5ost th$ 2innin. Wor1(s( in its/th$ir $ntir$ty on th$
CPMA W$#sit$ to $n%#,$ th$ 5"#,i- to 'o2n,o%' it or r$$.
YES NO
( declare that ( ha6e read the r3les of the co0test (the R",$s)1 a0d hereby accept the said "3les- ( hereby 4ra0t a0d assi40 to the Carlos Pala0ca Fo30datio01 (0c-1 (the S5onsor)
the -on-"rr$nt %n' non7$8-,"si/$ ri4ht to e9ercise the f3ll copyri4ht a0d all other i0tellect3al property ri4hts 4ra0ted to the a3thor a0d the a3thor:s assi40ees1 2ith respect to a0y 2i00i04
2or5(s)1 i0cl3di04 all of my pre6io3s Pala0ca *2ard pri;e < 2i00i04 2or5(s) if a0y1 (collecti6ely1 the Wor1(s()1 to the e9te0t permitted 30der e9isti04 la2s applicable at the time of
e9ercise- =his 4ra0t a0d assi40me0t also e9te0ds to all forms of stora4e1 tra0smissio01 dissemi0atio01 a0d comm30icatio01 prese0tly e9isti04 or s3bse>3e0tly created- =o the e9te0t
permitted by la21 this 4ra0t a0d assi40me0t of ri4hts shall be 2orld2ide1 co0ti03o3s1 a0d may be e9ercised by the 'po0sor for the ma9im3m time allo2ed by applicable la2- =he pri;e
mo0ey 2hich may be a2arded to me for a0y of the !or5(s) shall co0stit3te f3ll payme0t of the fore4oi04 ri4hts assi40ed to the 'po0sor1 a0d shall be i0 lie3 of a0y royalties or other
compe0satio0 to me-
( hereby 30derta5e to i0dem0ify the 'po0sor1 its directors1 officers1 employees1 co0s3lta0ts1 a0d a3thori;ed represe0tati6es1 for a0y a0d all dama4es1 liabilities1 claims1 losses1
a0d fees1 i0cl3di04 reaso0able attor0ey:s fees1 i0 the e6e0t that a0y of the !or5(s) i0fri04e the i0tellect3al property ri4hts of a0other-
A"thor)s Print$' N%!$ A"thor)s Si.n%t"r$
(NOTE: (f the participa0t is a mi0or1 the follo2i04 sho3ld be accomplished by the pare0t or le4al 43ardia0-)
PARENTAL CONSENT
(For co0testa0ts 2ho are mi0ors-)
(1 the 30dersi40ed pare0t a0d$or le4al 43ardia0 of ???????????????????????????????????????1 hereby e9ec3te this doc3me0t o0 his$her behalf-
?????????????????????????????????
Print$' N%!$ %n' Si.n%t"r$
(Pare0t$,e4al @3ardia0)
AC4NOWLEDGMENT
"ep3blic of the Philippi0es)
) '-'-
%FO" M1 this ???? day of ?????????????????????1 i0 ????????????????????1 Philippi0es1 perso0ally appeared:
)ame @o6er0me0t/iss3ed 6ide0ce of (de0tity +ate$Place of (ss3e$Aalidity Period
50o20 to me a0d to me 50o20 to be the same perso0$s 2ho e9ec3ted the fore4oi04 i0str3me0t a0d 2ho ac50o2led4ed to me that the same is his$her$their 6ol30tary
a0d free act a0d deed-
+oc- )o- ????B
Pa4e )o- ????B
%oo5 )o- ????B
'eries of 201?-