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TESTIMONIAL RELEASE FORM

I give my permission to Henry Schein Tier Three Brokerage LTD, its subsidiaries and affiliates and/or any successor and/or assignee to use, display, digitize, reproduce, and distribute (collectively, “Use”) my testimonial, letter of recommendation or other feedback (whether written, oral, recorded or otherwise) in its marketing materials, in any media, and on its website, or the mobile version thereof.

Henry Schein Tier Three Brokerage LTD may also include my full name or initials, title, and city, state. This identification information along with my testimonial, letter of recommendation or other feedback shall be referred to together as a “Testimonial”. I agree that Henry Schein Tier Three Brokerage LTD may, in its discretion, Use the Testimonial, use excerpts therefrom, or edit my Testimonial, so long as it such editing does not create a misleading impression of my views, and may Use the original or edited Testimonial or excerpts therefrom. I hereby transfer and assign all rights, title, and interest in and to the Testimonial, including but not limited to perpetual worldwide copyright rights thereto, to Henry Schein Tier Three Brokerage LTD. I hereby waive all rights under privacy, publicity, defamation, and proprietary rights relating to the Testimonial.

I represent that my Testimonial is a true and accurate depiction of my experience and that I have not been compensated by Henry Schein Tier Three Brokerage LTD for such Testimonial. I represent that I have the right to enter into this Release Agreement. I release, indemnify, and hold Henry Schein Tier Three Brokerage LTD, its licensees, successors, and assignees harmless against all claims, liabilities, and expenses arising out of the breach of any of my representations or promises.

I have read and understand the terms and conditions of this Release Agreement and acknowledge that I am providing my electronic signature for the release of my testimonial.