Submissions Form

By signing below, I grant to Olympus Corporation and/or its affiliated companies of the Olympus Group (a list of such affiliates can be found at www.olympus.com), including their respective legal representatives, assigns and those acting with its authority or permission, (collectively, “Olympus”) the nonexclusive, worldwide, irrevocable, and royalty-free right to use, re-use, reproduce, publish, distribute, exhibit, represent, communicate, create, copyright derivative works, to make or exploit adoptions or other transformations, assign rights to, and depict and display the image and/or picture, or any part thereof, taken by me on

at

and as set forth on Exhibit A attached hereto (the “Image”) for purposes of inclusion in Olympus brand or product promotions, marketing, education, or any and all forms of public display, relations and communications (the “Purpose”) in any and all formats and media now and hereafter known, including but not limited to printed form, web-based or other electronic form, or interactive presentation, including trade shows.

I waive the right to inspect, review or approve the finished product or products produced by Olympus using the Image.

In addition, I release and agree to hold harmless Olympus from any liability by virtue of the use, production or reproduction of the Image, my name and/or image and/or the name of my company/institution (if applicable) for the Purpose outlined above, including without limitation any claims for libel or violation of any right of publicity or privacy. In no event shall Olympus be liable for direct, indirect, special, incidental or consequential damages arising from its use of the Image for the Purpose, regardless of the theory of liability.

I represent that I am of full age and have the right to contract in my own name, and if I am employed by a company/institution, that I have the authority to execute this Release and Consent on behalf of my company/institution. This Release and Consent shall be binding upon me and my legal representatives and assigns, or if I am signing on behalf of my company, the company’s directors, officers, legal representatives and assigns. I also agree that a faxed, scanned, or electronically reproduced or transmitted signature constitutes an original signature.

ACCEPTED AND AGREED: