Motives® by Loren Ridinger®

1302 Pleasant Ridge RoadGreensboro, NC 27409

Phone: 866-420-1709www.motivescosmetics.com

* Please remember to include a head shot when submitting

your application.* Applications not completed in their

entirety will be disqualified.

* Entries are due by: December 31, 2011.

MODELSEARCH2012MOTIVES®

Motives Model Search Application Form,Release & Waiver

Date:

Name:

Address:

City/State:

ZIP/Postal Code:

Phone:

Phone 2 (optional):

Email:

Age:

Have you ever been convicted of a crime? yes noIf yes, please explain:

Ihaveread,understandandagreetotheMotivesModelSearchofficialrules.

ReleaseandWaiverforMediaPurposes

I hereby authorize Market America, Inc., “MA”, to use my name, testimonial, any and all voice, video images, photograph(s) and other likeness submitted to MA, or posed, or taken by, or on behalf of MA, in marketing, materials, media and/or any news related programs for the purposes of marketing, selling or otherwise promoting Motives, Fixx™, Matriskin, Cellular Laboratories® and/or any other skin care or cosmetics products distributed by Market America, as well as in any promotional materials for Market America, Inc., including but not limited to events, promotions and products not previously mentioned.

I understand that my name, testimonial, photographs, voice, video image, or other likeness may be copied and distributed by means of various media, including, but not limited to, video presentations in any format, promotional materials, advertisments and/or internet or intranet websites, without any further authorization or notice to me.

I release and hold MA harmless from any and all liability for damages of whatever kind of nature which may at anytime result from this release and authorization or from the dissemination of my name, testimonial, photographs, video image or likeness.

I understand that I will not receive any compensation for this release and authorization and waive any and all rights, compensation, royalties, or other payment in connection with the use of my name, testimonial, voice, photographs, and other images.

PrintedName: Initials:

Filloutandsaveapplication.Sendittomotivesmodelsearch@marketamerica.com

—The 2011 Motives Model Search Winner—

ALLYSSA DEOROCKI