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).

2. The rights granted to the Producer hereunder are conditional upon and subject to the
following:

(a) The Presentation shall not be used for any other purpose without the prior written
consent of the undersigned;

(b) The Presentation will not be sold or reproduced for any other commercial or non-
commercial purpose; and

(c) The Producer acquires no rights or interest in any trademarks or other intellectual
property rights of the undersigned.

Date

Witness Name of Person Giving Permission to

Film/Video