Photo Submission Form

Operative Dentistry, Inc. Copyright Assignment – Non-Manuscript

I, the undersigned, (hereafter “Provider”) irreversibly grant to Operative Dentistry, Inc., its officers, employees, agents,
assigns, successors, licensees, and members of the Executive Board of Operative Dentistry and/or related entities, and
their respective employees, agents, and representatives (collectively called “Jopdent”), the full right to create and obtain,
in the past, present, and in the future, images, photographs, video, audio, interviews, and any other recordings,
documents, or materials in any now known or future media, of the submitted work, titled:

(collectively called “Recordings”). Provider also authorizes Jopdent to copyright, adapt, edit, translate, summarize,
reproduce, perform, display, distribute, publish, license, sublicense, sell, broadcast, post or stream over the internet, and
otherwise use and allow others to use any and all parts of the Recordings, forever and throughout the world, in any and
all manners, and in any and all forms of media that Jopdent believes suitable. Provider waives the right to inspect or
approve such materials created and/or used by or on behalf of Jopdent pursuant to this release.

Provider agree that Provider shall have no right, title, or interest in or to the Recordings (or to any work comprising or
based on the Recordings, in whole or in part), and that all right, title, and interest in and to the Recordings belongs to
Jopdent. Provider waives any and all right to payment or other compensation arising from or related to the Recordings.
Provider will not state or imply, or allow others to state or imply, that Jopdent approves of or endorses Provider or
Provider’s activities. Provider further agree to release, defend, and hold Jopdent harmless from any claims, damages, or
liabilities related to the Recordings or Jopdent’s use thereof. Provider understands that this release is governed by the
laws of the State of Indiana, USA.

Jopdent is permitted, though not obligated, to include Provider’s name as a credit in connection with the use of the
Recordings. Jopdent is not obligated to utilize any of the rights granted in this agreement.

Upload your photo here. We allow one photo per submission. The photo must be in jpg, jpeg, or png formats. We allow up to a 10MB file size. the photo should be, at a minimum, 5 inches on the shortest side and at least 1500 pixels on the shortest side.

Select the correct statement:
—Please choose an option—My image contains the likeness of a person(s) that may be recognized by a close friend of the person(s). I understand that Addendum 1 of this Release MUST be completed.My image DOES NOT contain the likeness of a person(s) that may be recognized by a close friend of the person(s).

Select the correct statement:
—Please choose an option—My image contains the likeness of private property that may be recognized by an employee or owner of the property (the “property” may be the likeness of a company logo, trademark, etc. as well as real estate.) I understand that Addendum 2 of this Release MUST be completed.My image DOES NOT contain the likeness of private property that may be recognized by an employee or owner of the property (the “property” may be the likeness of a company logo, trademark, etc. as well as real estate.)

Recordings will be held for 24 months from the date of submission. If the Provider has not received notice of acceptance
and intended use of the Recordings within that time period, the Recording will be purged from Jopdent files, and all rights
and assigns will be transferred back to the Provider. During this 24 month period, and thereafter if the Recordings are
used by Jopdent, Jopdent grants use of the Recordings to the Provider for incidental personal home/family uses only. Use
for any other purpose whether commercial or noncommercial in nature, whether paid or unpaid, is strictly prohibited.

Provider has read and understood this agreement and the Provider is over the age of 18 or the age of majority (full age)
in Provider’s jurisdiction – whichever is later. This agreement expresses the complete understanding of the parties. By
signing below, Provider represents that Provider has read this Release, understands its contents, and agrees to this
Release.

Sign, date and provide further description of the Recordings

Your name as typed below will act as your signature to this statement.

Any signature (including any electronic symbol or process attached to, or associated with, this statement and adopted by a Person with the intent to sign, authenticate or accept such contract or record) hereto shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based record-keeping system to the fullest extent permitted by applicable law.

Your Name/Signature (required)

Your Email (required)

Date of this submission

Address
"Full postal address"

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Recordings details (briefly describe the Recordings for archival and retrieval purposes):

Location of the Recordings

Camera and Lens used to take the image (if applicable)

Date of the image