I hereby consent to be photographed, filmed, videotaped, recorded, quoted and/or have my personal likeness recorded through other visual means (collectively, referred to as "Personal Images and Quotes"), and authorize DiaSorin Inc. and/or its affiliates and authorized agents (collectively, "DiaSorin") to use, release, publish, exhibit, disclose, post on the Internet, in flash drives or any other medium any of my Personal Images and Quotes, as described below and understand and acknowledge, by signing this consent and release form, the following:
By signing this form, I hereby give permission to DiaSorin to publish, disclose and/or use my Personal Images and Quotes in whatever medium deemed appropriate by DiaSorin for any of the following purposes: (i) educational and research purposes, (ii) publication in professional journals, (iii) collateral and promotional materials, (iv) web-based marketing materials including website content, (v) public and media relations, or any other advertising methodology ("Authorized Purposes").
I hereby acknowledge and represent that the provision of any Personal Image or Quotes for DiaSorin's use hereunder does not conflict with any policy of my employer or give rise to any other conflict of interest and that if my Personal Image or Quotes contain images, tradenames, trademarks or logos of my employer, I am authorized to use and to allow use of such images, tradenames, trademarks or logos by DiaSorin.
I understand that my Personal Images and Quotes may be seen, published, disclosed and used by DiaSorin throughout the world and hereby consent to such worldwide publication, disclosure and/or use of such Personal Images and Quotes for the purposes stated in this consent form. I understand that my consent is voluntary, that I am not required to sign this consent and release form and that I may in fact refuse to sign it, and thereby prohibit DiaSorin from obtaining, publishing, disclosing and/or using any Personal Images and Quotes of me.
I have the right to revoke my consent allowing DiaSorin to publish, disclose and/or use my Personal Images and Quotes at any time, which revocation must be in writing and submitted to:
DiaSorin Inc.Attn: Legal Affairs1951 Northwestern Ave.Stillwater, MN 55082
I release and discharge DiaSorin, its officers, agents, employees and each and all persons involved in creating my Personal Images and Quotes from any liability connected with the taking, recording, filming, production, disclosing and/or publishing of such photographs, slides, computer images, videotapes and/or quotes.
I waive all rights I may have claims to for payment or royalties in connection with any exhibition, televising, Internet posting, or other publication or other disclosure of my Personal Images and Quotes, irrespective of whether a fee for its use is charged by any third party. If I have any questions about my privacy rights under this consent and release form, I understand that I may contact DiaSorin. I declare that I am eighteen (18) years old or older and am legally competent to execute this consent and release form. I understand that the terms herein are contractual and not a mere recital, and that this consent and release form is legally binding on me. I have read and fully informed myself of the contents of this consent and release form before signing it. I have had the opportunity to ask questions about the disclosure, publication and/or use of my Personal Images and Quotes, understand their purported use, knowingly consent to the publication, disclosure and/or their use and voluntarily sign this consent and release form.
Name of Individual: ________________________________________________________________
Signature of Individual: _____________________________________
Address of Individual: ________________________________________________________________