Department Recognition Collection Form

I understand and acknowledge that my employer, InterWest Insurance Services, LLC (“InterWest”), or its employees, agents or assigns may periodically take photographs, video or audio recordings of me related to my employment, and I consent to such activity. I hereby grant permission to InterWest to use my name, image, likeness and sound of my voice as captured and/or recorded in any format or media without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my image or recording appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. In compliance with California Civil Code Section 3344, I hereby agree to allow InterWest to use my name, image, likeness and sound of my voice for any commercial, advertising, promotional, employee relations, administrative, news, or public relations purpose in print and/or electronically indefinitely, including after my employment with InterWest ends. I understand and acknowledge that signing this Consent and Release is voluntary and is not a condition of my employment. I may revoke this Consent and Release at any time by completing the Revocation of Consent and Release form and submitting it to Human Resources. I am at least 18 years of age. I have read and understand this Consent and Release. I voluntarily agree to it.

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