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Model Application & Release

RECORDS KEEPING COMPLIANCE FORM PURSUANT TO 18 U.S.C. § 2257

 

MODEL IDENTIFYING INFORMATION AND AFFIDAVIT: Model understands that all the information given in this Agreement is being provided to comply with federal law and any false statement will subject Model to both a civil action by Producer as well as criminal prosecution under federal and state law.	Please Enter Your Initials In The Box Above If you Agree & Understand the Statement entitled: Model Identifying Information and Affidavit <<-----------------------------------
What's Your Legal Name?: (First, Middle, Last)
What's Your Age?:
The aforementioned information was acquired by the mandatory examination of the following Two Forms of Identification, including at least one government-issued photo identification document such as a Valid Driver's License or a Passport: (Each should be described, including the ID number. Clear, good-quality photocopies of each must be attached to this Form and the photocopies must be signed in ink by Model): Note: If ID does not contain a recent and recognizable picture of the Model, only a Drivers' License, State ID Card or Military ID will be acceptable for U.S. Models; and only a passport will be acceptable for foreign Models, in such circumstances. Unless both the Model and the producer are located outside the U.S., a 'picture identification card' as defined in CFR 75.2(a)(1) must be examined to ascertain the model's legal name and date of birth prior to completing this form.
First Form of Identification: (What Type & ID Number)
Attach 1st ID
Second Form of Identification: (What Type & ID Number)
Attach 2nd ID
All other names ever used (include all stage names, Web handles, maiden names, aliases, professional names and nicknames):
OTHER INFORMATION
Attach A Picture of Yourself
Attach A Picture of Yourself
Enter Your Email Address:
Tell Us About Yourself: i.e. height, weight, hair & eye color, etc.
Referred By	Internet Business Card Flyer Radio Television Yellow Pages Word of Mouth
MODEL PLEASE AGREE & SIGN BELOW
SWORN STATEMENT: "UNDER 28 U.S.C. §1746 AND THE PENALTIES OF PERJURY UNDER THE LAWS OF THE UNITED STATES, I SWEAR THAT THE FOREGOING IS TRUE AND CORRECT AND THAT EACH OF THE IDENTIFICATION DOCUMENTS WHICH I HAVE PROVIDED AND OF WHICH I HAVE SIGNED THE ATTACHED COPY WAS LAWFULLY OBTAINED BY ME AND HAS NOT BEEN FORGED OR ALTERED."	Today's Date   I also agree that this transaction is governed by the Electronic Signatures in Global and National Commerce Act (E-Sign Act),15 U.S.C. §7000, et seq., and adopt the mark below as my electronic signature for purposes of this form. E-Sign: X
FOR PRODUCER (PHOTOGRAPHER) ONLY - MODELS AGREE ABOVE
UNDER 28 U.S.C. §1746 AND THE PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES, I SWEAR THAT THE FOREGOING IS TRUE AND CORRECT, THAT I HAVE PERSONALLY EXAMINED THE MODEL'S PHOTO IDENTIFICATION AND DATE OF BIRTH, THAT I HAVE PERSONALLY QUESTIONED THE MODEL REGARDING THE ANSWERS GIVEN IN THIS AGREEMENT, AND THAT I HAVE OBSERVED THE ORIGINALS OF EACH OF THE IDENTIFICATION DOCUMENTS OF WHICH COPIES ARE ATTACHED HERETO AND SIGNED BY THE MODEL. IN ADDITION, I SWEAR THAT THE DATE SET FORTH BELOW IS THE DATE ON WHICH PRODUCTION OCCURRED.	Today's Date   I also agree that this transaction is governed by the Electronic Signatures in Global and National Commerce Act (E-Sign Act),15 U.S.C. §7000, et seq., and adopt the mark below as my electronic signature for purposes of this form. E-Sign: X