Date MM slash DD slash YYYY Name* First Last Email* Facility Name* Facility Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Attached video can be used for promotional and marketing purposes. Video Consent*I authorize Dignitana AB and its subsidiaries and affiliates (collectively, “Dignitana”) and hereby give my permission to Dignitana to utilize photographs and/or videotape of me (whether taken by Dignitana or submitted by me), as well as any derivatives of the photographs or videotape, on its website(s) and to incorporate the photographs and/or videotape into other media and materials, including, marketing and public relations materials (collectively, the “Production Materials”). I give my authorization to use the above information in the manner set forth above and understand and acknowledge that: (i) although my name will not be published in any of the Production Materials, anonymity cannot be guaranteed, (ii) with this authorization, I release Dignitana from any and all liability that may arise from the use of the Production Materials consented to above, (iii) the Production Materials consented to above are the property of Dignitana and may be used in future projects, (iv) the Production Materials may be subject to re-disclosure by another party and thus may no longer be protected by HIPAA or under the terms of this authorization, (v) I will not receive any compensation if the Production Materials are released and/or used by Dignitana or any other party that may obtain the Production Materials in the future, and (vi) this authorization will expire fifty years from the date of this authorization. I do not have to sign this authorization and I may cancel this authorization at any time. If I do, Dignitana will take reasonable steps to cease using the Production Materials. However, I understand that by cancelling this Authorization, my cancellation will not affect the Production Materials disclosed by Dignitana prior to its receipt of my cancellation or with respect to any commitments made by Dignitana prior to its receipt of my cancellation. The cancellation is note effective to the extent that any person or entity has already acted in reliance on my authorization. I give my authorization to use the above information.Upload VideoMax. file size: 256 MB.