APPLICATION AND MEDIA RELEASE FORM

Video Title: Total Running Time: __:__ (minutes:seconds) Name/s of Producer/Director: Main contact person (If more than one producer/director): Address (of main contact person, if more than one): Home/Mobile Number: E-mail Address: Birthdate (MM/DD/YY):
Photography/Video/Digital/Film Rights and Clearance Agreement Media entrant warrants that s/he is 25 years and below, the owner of the work; holder of the copyright thereon, possesses all rights therein, and can rightfully enter into this agreement. Entrant further warrants that all rights, clearances, releases and licenses necessary for promotion or cablecast of this work have been secured so that worldwide website exhibition, broadcasting or cable casting will not oblige Mulat Pinoy and/or any employee thereof to make payment to any third party, and that there will be no violation or infringement upon any rights of any person, firm, or corporation, including, without limitation, rights to privacy and publicity. Entrant agrees to grant Mulat Pinoy the right to use his/her digital media, videotapes, photographs and/or any other form of images from said entry for promotion, website exhibition, cablecast, educational or not-for-profit sale, and distribution or use. Media Entrant agrees to indemnify, defend, and hold harmless Mulat Pinoy, its Governing Board, officers, agents, employees, and or any employee or representative of Mulat Pinoy from and against any and all claims, damages, liabilities, costs, expenses, negligence, or claims of negligence, including but not limited to attorney's fees, which may be incurred by reason of any breach, or claim of breach, of the within representations and warranties or arising out of any matter contained in the entry or by use of the entry as agreed hereunder. By submission of this media entry and my signature below, I agree to the above stated conditions and warranties described in the Photography/Digital/Video/Film Rights and Clearance. Mulat Pinoy reserves the right to disqualify entrants that contain any copyrighted material. All materials submitted will not be returned.

Signature/s: ____________________ Date: ____________ Print Name: _____________________Title: ____________ In the event the individual is a legal minor, Parent or Legal Guardians Signature for main contact person is required: Parent/Legal Guardians Signature over Printed Name: ______________________________ Relationship: ______________________________

Mulat Pinoy Probe Media Foundation, Inc. Unit 505 Sterten Place Condominium, 116 Maginhawa Street, Teachers Village East, Quezon City 1101 Philippines Tel (+632) 433-0456 Fax (+632) 433-0457 Email. popdev@mulatpinoy.ph, wearerh@mulatpinoy.ph www.mulatpinoy.ph/wearerh