Name *
First *
Last *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Phone *

Email *
Upload Photo for Tile *

Wording that is to be used on the tile (32 max characters including spaces) *

Tile Package *

 Option 1: $40 
 Option 2: $75 

Tiles will be available for pick-up at Taubman Prestige Outlets’ management office during mall hours. Your receipt is required for pick-up. Taubman Prestige Outlets is located at 17017 N. Outer 40 Rd. in Chesterfield, Missouri. If you have questions regarding tile pick-up, please contact mall management at (636) 812-0570.

I hereby assign and grant to Taubman Prestige Outlets and The Taubman Company, LLC, the right and permission to use and publish the photographs/tiles of me and my dog by Lee Printing Company, and I hereby release, waive and discharge Taubman Prestige Outlets and The Taubman Company, LLC, their directors, employees, agents, partners and affiliates from any and all liability to me my personal representatives, assigns, heirs, and next of kin for any loss or damage, and any claim or demand therefore from such use and publication whether caused by negligence or otherwise.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage and/or distribution of said photographs/digital files/electronic representatives without limitation at the discretion of Taubman Prestige Outlets or The Taubman Company, LLC, and I specifically waive any right to any compensation I may have for any of the foregoing.

I have read and voluntarily sign this Release and Assignment and further agree that no oral representations, statements, or inducements apart from the foregoing written agreement have been made.