If you wish have us use a copyrighted photograph (noted on the back of the photo, stamped with a company logo on the front, or otherwise obviously copyrighted), you may print, sign (or have your photo studio sign), and fax this page to 803-548-9782 or include it with your mail-in order. 

Customer Name:  _______________________________

Address: ______________________________________

 Phone Number: _________________________________

 Brief Photo Description: __________________________

I certify that I am the copyright holder (I am the original photographer or I possess the original negatives/digital image) of the above described photo presented for the sole use of Photo-Gems Ltd to produce jewelry items for the above listed customer only.  OR, if I am not the copyright holder, I have written permission from the photographer for such use and have included a copy with this form.  OR  the photograph was taken prior to 1978 and the studio is no longer in business.  OR the photograph was taken prior to 1938.

___________________________________________      _________

Photographer's Signature or Customer's Signature           Date    

__________________________________________

Print Name and Studio (If applicable)