Merck KGaA, Darmstadt, Germany and/or any of its affiliates, including but not limited to EMD Millipore Corporation, Millipore SAS and Sigma-Aldrich Co LLC (hereinafter, “Authorizer”) grant permission to _____________________________________ (hereinafter, “Requester”) for _____________________________________the use of the photograph(s) or electronic media images (hereinafter, “Works”) as identified below for [insert purpose and medium of publication (electronic, printed)].
Information on Photograph(s) and Images2
☐ Image 1
☐ Image 2
☐ Image 3
☐ Etc.
Type of Use (check one):
☐ For profit
☐ Not for profit
This consent has been read and agreed by Requester on
Signature: _________________________________________________________
Authorized Representative(s): _________________________________________________________
Date: _________________________________________________________
Authorizer
Signature: _________________________________________________________
Authorized Representative(s): _________________________________________________________
Date: _________________________________________________________
Signature: _________________________________________________________
Authorized Representative(s): _________________________________________________________
Date: _________________________________________________________
1 Once completed, please send it to copyright@milliporesigma.com
2 Please insert information that describes the photograph or the image. (Submit a photocopy or screen image of the context in which the copyrighted
material will be used)
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