"I Corti sul lettino .- Cinema e psicoanalisi"

RELEASE FORM FOR THE UTILIZATION OF THE SHORT FILM

Me, undersigned_________________________________________ born at

________________________________ State_______________________________

the____/_____/ _____/ Address_____________________________________

fiscal code number________________________________________________

e-mail_______________________________________________________________

telephone number_________________________________________________

I concede the release form to the organization of the Contest

“I corti sul lettino. Cinema e psicoanalisi”(IV edizione) for the

utilization, according to the terms specified in the rules of the

contest, of the SOUNDTRACK of the SHORT FILM named:

________________________________________________________________________

________________________________________________________________________

Date___/_____/____

Sincerely,________________________