ANNEX “__”

CONSENT FORM
(To use Intellectual Property)

I/We, the undersigned, own the copyright/trademark/patent/other IP rights pursuant

to the provisions of the Miriam College IP Policy. I, do hereby grant to: Miriam College,
its assigns, the absolute one-time right to use, publish and reproduce such intellectual
property in whatever form, electronic or otherwise, as originally produced unless a
written agreement detailing any changes to the materials is obtained between me and the
organization to which I am providing consent.

Attached to this consent form are the original materials to which I/WE am/are
providing consent to use and any written agreement regarding changes to the original
materials.
(Description of materials attached to this form)

This consent given to the above-named organization is limited to using the

materials as originally produced and limited for teaching, research and non-commercial
and academic purposes, unless a written agreement is obtained between me and the
above-named organization for the use of the works other than that I/we consented to, to
alter the materials and in which all changes to the original materials will be noted. This
consent and release shall be binding upon me and my heirs, legal representatives, and
assigns.

Name of Owner