CARLOS PALANCA MEMORIAL AWARDS FOR LITERATURE

c/o CPMA Research Facility

6F Unit 603 Park Trade Center
1716 Investment Drive, Madrigal Business Park, Ayala Alabang, Muntinlupa City 1770

Year: 2016

CONSENT (FOR DERIVATIVE WORKS)

(This form must be notarized.)
1.

INITIAL WORK(S) FROM WHICH THE ENTRY IS DERIVED

TITLE

TITLE WHEN PUBLISHED OR

PRODUCED
(IF APPLICABLE)

PUBLISHER/PRODUCER

DATE(S) OF
PUBLICATION/PRODUCTION

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2.
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5.
I represent and warrant that I am the author, publisher, or producer, of the work(s) listed above (the Initial Work(s)) and that I am the absolute owner of the
copyright(s) and all other intellectual property rights pertaining to the said Initial Work(s). I hereby acknowledge that _____________________ (the Contestant)
has created a derivative work based on the Initial Work(s). I hereby give my consent to the (Contestant) to enter the derivative work(s) listed below (the
Derivative Work(s)) as his own, in the Carlos Palanca Memorial Awards for Literature contest (the Contest) for the current year.

TITLE OF DERIVATIVE WORK/

TITLE OF INITIAL WORK FROM WHICH SUCH
WORK IS DERIVED

DIVISION

CATEGORY

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2.
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5.
I declare that I have read the 2016 Rules of the Contest (Rules) and hereby accept such Rules, and I acknowledge the Sponsors Rights over the Derivative
Work(s). SAVE IN THE CASE OF FRAUD, GROSS NEGLIGENCE, OR BAD FAITH, I HEREBY HOLD THE SPONSOR FREE AND HARMLESS FROM ANY
INFRINGEMENT OF INTELLECTUAL PROPERTY RIGHTS WHICH MAY ARISE IN CONNECTION WITH THE CONTEST AND/OR THIS CONSENT, AND
SHALL HAVE NO RECOURSE AGAINST THE SPONSOR AT LAW OR EQUITY. For purposes of this clause, Sponsor shall mean the Carlos Palanca
Foundation, Inc., its directors, officers, employees, consultants, and authorized representatives.

______________________________________________________
Printed Name of Initial Work/s Owner Giving the Consent

Signature

(NOTE: If the person giving consent is a minor, the following should be accomplished by the parent or legal guardian.)
PARENTAL CONSENT
(For contestants who are minors.)
I, the undersigned parent and/or legal guardian of _______________________________________, hereby execute this Consent on his/her behalf.
_________________________________
Printed Name and Signature
(Parent/Legal Guardian)

ACKNOWLEDGMENT
Republic of the Philippines)
) S.S.
BEFORE ME, this ____ day of _____________________, in ____________________, Philippines, personally appeared:
Name

Government-issued Evidence of Identity

Date/Place of Issue/Validity Period

known to me and to me known to be the same person/s who executed the foregoing instrument and who acknowledged to me that the same is his/her/their
voluntary and free act and deed.
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 201_.