Address:

___________________

___________________

___________________

FILM TITLE: <put title here>

DATE OF FILMING: ___________________

By signing this form, I hereby consent to the filming and recording of my performance in the film ______________, the nature of which has been fully explained to me, subject to the terms and conditions specified below.

I hereby agree that the copyright, ( if any ), and all other rights, title and interest in, and in respect of my contribution shall vest in, is hereby assigned to __<production company name>____, (the PRODUCERS of the film) or its licensees, ( and this assignment shall operate to the extent necessary as a present assignment of future copyright ).

I hereby give all consents necessary for the reproduction, exhibition, transmission, broadcast and exploitation of___<film title>, (in whole or in part ), without limit, throughout the universe, by all means and media, ( whether now known, or hereafter invented), without liability or acknowledgment to me.

__<PRODUCTION COMPENY >__ shall be entitled to edit and cut the

footage as it deem fit, and shall not be obliged to include all, or any of the same in any programme.

Signature:

Print name:

Date: