CONSENT TO RECORD

(Date)

(Location)

I,
(Name)
, hereby authorize
(Address)
and ,

representatives of ________________________________, to place a Body Recorder on

(Company Name)

my person for the purpose of recording any conversation with

that I might have on or around .

(Name of Subjects) (Date)

I have given this written permission voluntarily and without threats or promises of any kind.

(Signature)

Witnesses: