Talent Agency — Payment Authorization

Check Authorization & Direction to Pay

You are hereby notified that I have authorized {TALENT AGENCY} (the “Agency”) to receive, accept delivery of and to endorse, deposit and/or negotiate, and to deduct its commission on the undersigned’s behalf from, any and all checks and/or sums of money which may, from time to time, be or become payable to me from you; and I hereby authorize you to send all such checks and/or sums of money to:

{TALENT AGENCY}
{TALENT AGENCY ADDRESS 1}
{TALENT AGENCY ADDRESS 2}
{TALENT AGENCY CITY STATE ZIP}

This authorization shall remain in effect until written notice of the revocation thereof, executed and acknowledged by me, shall be served upon you by registered mail.

I hereby agree to indemnify and save you free and harmless of and from any and all loss, cost or expense which may be incurred or suffered by you by reason of any action taken by you in reliance upon this authorization.

Agreed and Authorized — The Undersigned (Talent)
Signature of Undersigned
{SIGNING DATE}
Date
{MODEL NAME}
Printed Name of Undersigned