CARLOS PALANCA MEMORIAL AWARDS FOR LITERATURE 2011 c/o Carlos Palanca Foundation, Inc.

6/F One World Square Bldg., 10 Upper McKinley Road, McKinley Hill Town Center, Fort Bonifacio, 1634 Taguig City

AUTHORIZATION
I am hereby entering the enclosed work(s) listed below in the Carlos Palanca Memorial Awards for Literature contest (the Palanca Awards) for the year 2011. I represent and warrant that I have written or created the said work(s) and that I am the absolute owner of the copyright(s) and other intellectual property rights pertaining to the said work(s). I declare that I have read the rules of the contest (the Rules), and hereby accept the said Rules and the right of the Carlos Palanca Foundation (the Sponsor) to the publication/presentation/re-publication and/or dissemination of all winning entries as provided therein in any manner or form, including through the Internet. Pursuant to R.A. No. 8293, and in order to give public access to the winning works, I hereby grant assign, and transfer unto the Sponsor or its assignees, the right, without necessity of any payment other than the prize which may have been awarded: to publish from time to time any winning entry or selection or portion thereof as it may at its discretion determine; to designate or appoint editors to edit the work or any portion thereof to suit the demands of publication; to furnish a reasonable number of copies of all winning works to the National Library or other libraries; to make the works available for downloading on the Internet or other electronic media; and/or to allow students to make copies for research or in connection with their school requirements. In the One-act Play, Full-length Play, and Dulang Pampelikula categories, I also grant, assign, and transfer to the Sponsor the right to produce, or authorize the production of, and/or carry out the staging, telecasting, broadcasting, cinema, or other forms of exhibition whether over the Internet, through other electronic media, or on location, from time to time, any winning entry or selection or portion thereof as it may in its discretion determine. The Sponsor shall also have the right to appoint or designate editors or directors who may edit the work or any portion thereof to suit the demands of production or exhibition. The prize money which may be awarded to me for any of the enclosed work/s shall constitute full payment of said right of the Sponsor to publish, re-publish, present, produce, furnish or make available copies of such work/s to other parties or allow the latter to make copies thereof, and shall be in lieu of any royalties or other compensation to me. Furthermore, I hereby authorize and confirm the authority of the Sponsor to publish, present, re-publish, disseminate, or make available for downloading on the Internet or other electronic media all of my previous prize winning work/s in the Palanca Awards and the enclosed work/s, if so designated in the Official Entry Form, without necessity of any payment other than the prize/s already awarded. It is understood, however, that in the future, I may request the Sponsor not to include my work/s on the Internet or other electronic media by giving written instructions to that effect, in which case my said work/s shall be excluded from the Internet archives of the Palanca Award-winning works. TITLE 1. ______________________________________________ 2. ______________________________________________ 3. ______________________________________________ 4. ______________________________________________ 5. ______________________________________________ ________________________________________ Authors Printed Name and Signature Date: ____________________________ DIVISION ________________________ ________________________ ________________________ ________________________ ________________________ CATEGORY ________________________ ________________________ ________________________ ________________________ ________________________

Tel. No. ________________________________ Cell. No. _______________________________ Date of Birth ____________________________ (month/day/year)

(NOTE: If the participant is a minor, the following should be accomplished by the parent or legal guardian.)

PARENTAL CONSENT (For a contestant who is a minor)

The undersigned, being the parent and/or legal guardian of the minor who executed the foregoing authorization, hereby gives my consent and approval to his execution thereof.

_______________________________________ Printed Name and Signature (Parent/Legal guardian) IN THE PRESENCE OF: _____________________________________ REPUBLIC OF THE PHILIPPINES _______________________) S.S. BEFORE ME, a Notary Public for and in the City of ______________________________________ personally appeared ________________________________ with CTC No. ____________________________ issued at ______________ on ________________ and __________________________________________________ known to me and to me known to be the same person/s who executed the foregoing instrument and he (they) acknowledge to me that the same is the product of his (their) own voluntary act and deed. IN WITNESS THEREOF, I hereunto set my hand this ___ day of ______________ 2011 at Manila, Philippines. Doc No. ________________ Page No. _______________ Book No. _______________ Series No. ______________ ____________________________ NOTARY PUBLIC Until December 31, 201__ PTR # ______________________ Issued at ____________________ ________________________________