I, _____________________, understand that the Centennial Committee and the Historical, Educational & Memorial Center (Hereafter, Committee and HEMC), is conducting oral history interviews for the purpose of collecting and preserving the history of the Department, through the recollections of those individuals with knowledge of events or experiences which helped shape the heritage that is the Pennsylvania State Police.  I further understand that the Committee and HEMC will either conduct the interview(s) or cause the interview(s) to be conducted and that the Committee and HEMC will make the information gained there from available to researchers, educators, and the public.

            I authorize and grant to the Committee and HEMC permission to utilize any information obtained from the interviews in whatever form, including but not limited to videotapes and audiotapes and transcripts, for the above said purpose(s) including but not limited to copies of any negatives, prints and/or slides however created, and any reproductions thereof.  I hereby consent to such use for publications and advertisements of any kind in all media; and for any other lawful purpose whatsoever.  In further consideration, I waive all right of privacy in and to all of the above referenced items and information and relinquish all right, title and interest I may have in them including all rights under copyright law in the United States and throughout the world.  I understand that I WILL NOT receive any compensation either now or in the future for any use as is authorized by the Committee or HEMC.

            I further declare that I am of legal age and that no representations or promises have been made to me to secure the execution of this instrument, but the same is executed solely for the above stated consideration.  I grant permission to the Centennial Committee or its Agents, based upon legal review, to restrict access to any portion of my interview for a given period of time.  I also understand that I may designate portions of my interview to be restricted from access until my death.

This instrument is binding upon me, my heirs, executors, and administrators.