Permission to Film

TO: FULL NAME OF PARTY RECEIVING PERMISSION TO VIDEO (the "Producer")

In consideration of the sum of two dollars ($2.00) and for other good and valuable consideration (the receipt of which is hereby acknowledged), the undersigned, on behalf of himself and his respective heirs, executors, administrators, successors and assigns, hereby: 1. Acknowledges and agrees that the Producer shall have the right to videotape the Presentation without charge, for the sole purpose of State specific purpose for filming/video taping (ie. internal training of employees). The rights granted to the Producer hereunder are conditional upon and subject to the following: (a) (b) (c) The Presentation shall not be used for any other purpose without the prior written consent of the undersigned; The Presentation will not be sold or reproduced for any other commercial or noncommercial purpose; and The Producer acquires no rights or interest in any trademarks or other intellectual property rights of the undersigned.

2.

Date

Witness

Name of Person Giving Permission to Film/Video

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