Know All Men By These Presents, that I..............

of..............., in the State of..............., for and in consideration of $.........., paid to me by..........

.........., the receipt whereof is hereby acknowledged, do hereby grant, sell, assign and transfer unto said..........

.........., all right to take, make, manufacture, produce, reproduce, sell, lease, release, license, generally deal with and traffic in, exhibit, exploit and cause to be exhibited and exploited, motion pictures and photoplays based upon or taken from or adapted from a certain story entitled...............

and published in...............Magazine, in the issue of

.........., copyright whereof was registered by..........

..........on or about the..........day of.........., 19...

I hereby agree that I will not at any time in the future, sell, grant, transfer and convey unto any other person, firm or corporation, any rights or licenses which will in any wise conflict with the full, free and untrammeled enjoyment of the rights hereby granted, sold and transferred to................

In order to induce...............to make the payment to me above mentioned, I hereby warrant and represent:

1. That I am the sole author of the said story, that the same is not an adaptation of or plagiarism from any work published or unpublished, or any part of any such work, and that I am the sole and exclusive owner of the rights hereby granted, sold, transferred, and assigned, and to the whole thereof, free and clear of any lien, encumbrance, debt or charge of any kind or character whatsoever.

2. That the copyright of said story, except for the first American serial rights, has been transferred to me by said.........

....., by assignment...................., recorded in the

Copyright Office in Washington on......................

(or in the alternative delivered together with the delivery of this instrument to...........................for purposes of record in the Copyright Office.)

3. That the title of the aforesaid composition is such as may be used by........................in connection with motion pictures and/or photoplays based upon or adapted from said story.

In amplification of, and not in limitation of any rights hereinbefore specified as sold, assigned, transferred and granted unto said..............., I hereby specifically assign, grant, sell and transfer unto..............., the right to adapt, arrange, rearrange, change, transpose, add to and subtract from the said story as and to the extent that the said...............may deem expedient in the production of motion pictures and photoplays, and to the publication by said..............., its successors and assigns, of a synopsis of said motion pictures and/or photoplays when completed, for descriptive purposes and advertising and giving publicity to and exploiting the said motion pictures and/or photoplays.

In Witness Whereof, I have hereunto set my hand and seal this..........day of..............., 19...

..................[L.S.]