Your Full Name __________________________________________________________

Email Address  __________________________________________________________

Address _________________________________________________________________

City ________________________________________  State ______  Zip ________

Type of ID for proof of age  ________________  Date of Birth ____________

I hereby give  Internet Co., N.A. permission to scan the submitted photograph
as the photograph is of myself and no one else.  I further certify that
I possess full legal capacity to execute the foregoing authorization and
declare under penalty of perjury that all information is true and correct.

Your Signature ________________________________________  Date ____________

I, the photographer, hereby grant authorization to  Internet Co., N.A. to
scan the photograph in whole or part and return it for any lawful purpose.

Photographer's Signature ______________________________  Date ____________

Photographer's Printed Name ______________________________