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First State Bank Photo/Media Release Form

I hereby grant First State Bank/Town & Country Insurance permission to use my likeness in a photograph, video, or other digital media (“photo”) in all of its paper and electronic publications, including Facebook and other web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of the First State Bank/Town & Country Insurance and will not be returned.

I hereby irrevocably authorize the First State Bank/Town & Country Insurance to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose.  In addition, I waive any right to inspect or approve the finished product wherein my likeness appears.  Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge First State Bank/Town & Country Insurance from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ, UNDERSTAND AND ACCEPT THE ABOVE PHOTOGRAPH/MEDIA RELEASE:

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