PO Box 280480
San Francisco, CA. 94128-0480
415-552-2882 / 415-552-8444 Fax
www.d1musicnet.com
Authorization to use film footage shot June 26, 2004 in the 
Commercial release of the new Orgy music video "VAGUE"

To Whom It May Concern:

I, ____________________ am the legal guardian or parent of ________________________ and I voluntarily allowed my minor child to be filmed in the new Orgy music video.  I am authorizing D1 Music to use that footage in the new Orgy video that will be commercially released worldwide.  My minor child's participation in this video is authorized with my full knowledge that there is no monetary consideration being offered, suggested or implied. We hold D1 Music, Orgy, the director, production staff and all other third parties to this authorization agreement harmless from any form of liability or compensation now or in the future. If you have any questions please feel free to call 415-552-2882 prior to submitting this release form.

Sincerely,
_______________________________________
Parent Signature
_______________________________________
Parent Name (please print)
_______________________________________
Minor Signature
_______________________________________
Minor Name (please print

_______________________________________
Street Address: 
_______________________________________
City, State, Zip
_______________________________________
Telephone Number
_______________________________________
Date