I, __________________________(print full name)("Performer"), understand that all the information required by this document is required to comply with United States federal law and any false statement or misrepresentation is a crime under the United States law.

Two forms of identification, including at least one government issued photo ID, are required.  Describe each, including number.  Clear photocopies of each must be attached and the photocopies must be signed in BLUE ink by the performer.

(1) First form of identification:                 (2) Second form of identification:

_____________________________                _______________________________

Birth Date: _____________________________(Month/Day/Year)        Age: __________

I have also used the following names, stage names, aliases, nicknames and married and /or maiden names:

(1) _____________________________  (2) _____________________________

(3) _____________________________  (4) _____________________________

If more than 4 please attach a separate sheet, signed by the performer, with all names.

  Check this box to attest you have read and agree with the Terms of Use of Cam4 and you acknowledge you have licensed your images to Cam4 and you will keep all 2257 information in your files as you are the "producer" of said images.

PERFORMER'S SWORN STATEMENT:

I, ______________________________ (full legal name) pursuant to 28 U.S.C. §1746 and the penalties of perjury, under the laws of the United States, swear that the above is true and correct and that the ID which I have provided, a copy of which is attached and signed by me, was lawfully obtained by me and has not been forged or altered.

Today's Date: _____________________________

SIGNATURE: _____________________________

Performer's Signature (using full legal name)

WITNESS' SWORN STATEMENT:

Pursuant to 28 U.S.C. §1746 and the penalties of perjury, under the laws of the United States, I swear that I have personally examined the Performer’s ID containing the age of birth set forth above and I have observed the Performer execute this document and sign the attached copy of the ID.

 

_____________________________          _____________________________
Witness’s Signature                              Print Witness's Name
NOTE:  THIS DOCUMENT TO BE KEPT SEPARATE FROM ALL OTHER RECORDS