Photo-Authorization

Essential Service Solutions

2105 E. Cook #20635 Springfield,IL 62708

info@esssvcsol.com

(312)772-3148

Agent Portal

Signature: Date:

PHOTOGRAPH/MEDIA CONSENT AND RELEASE

I hereby consent and authorize an employee or agent of Essential Service Solutions
LLC(“ESS”) to take photographs or motion pictures of me; or to produce videotapes,
audiotapes, closed circuit television programs, web casts, or other types of media
productions that capture my name, voice, and/or image (any of the foregoing types of
media are called the “Materials” in this Consent and Release form).

I authorize Essential Service Solutions LLC to copyright the Materials, and I authorize
Essential Service Solutions LLC to use, reuse, copy, publish, display, exhibit, reproduce,
license to third party, and distribute the Materials in any educational or promotional
materials or other forms of media, which may include, but are not limited to Company
publications, catalogs, articles, magazines, recruiting brochures, websites or publications,
electronic or otherwise, without notifying me.

I also agree that Essential Service Solutions LLC may identify me by name, position, and
such other identifying information as promotional date, hometown, etc. (If the person
does not wish to be identified by name, etc., please have them cross through this
sentence, and initial year.) _______

I agree that I am participating on a voluntary basis and I will not receive any payment
from Essential Service Solutions LLC for signing this release or as a result of any
publication of the Materials.

I represent that I am at least 18 years of age.