RECORDS KEEPING COMPLIANCE FORM

PURSUANT TO 18 U.S.C. § 2257

MelTech, INC.

 

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.  _________

                                                                                                                                                    (Model’s Initials)

a.         Legal Name: _________________________              b.         Date of Birth: ____________

                                 (Full Current Legal Name: First, Middle, Last)                                                                              (Month, Day and Year)

                                                                                                            Age: _______________

 

c.         Primary identification document must be government issued passport, driver’s license, motor vehicle department ID, or military ID:  (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):

 

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

            ____________________________                ___________________________________

 

            ID # ________________________                ID # _______________________________

 

d.         All other names ever used (include previous legal names, stage names, Web handles, maiden or married names, aliases, professional names and nicknames):

(1) ____________________________           (a) _________________________________

                         (Stage Name for this Production)                                           (All other names)

            (2) ____________________________           (b) _________________________________

                         (Maiden Name if applicable)                                                   (All other names)

            (3) ____________________________           (c) _________________________________

                         (Previous legal name, if applicable)                                         (All other names)

 

e.          Phone # (      )_______________________ [Optional]

 

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.”

 

Signature:      _______________________________________         Today’s Date:___________

                      Model’s Signature (using full legal name)

 

MODEL MUST ALSO SIGN ATTACHED COPIES!

 

UNDER 28 U.S.C. §1746 AND THE PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES, I SWEAR THAT I BELIEVE THE FOREGOING IS TRUE AND CORRECT, THAT I HAVE PERSONALLY EXAMINED THE MODEL’S PHOTO IDENTIFICATION AND DATE OF BIRTH, AND THAT I HAVE OBSERVED THE ORIGINALS OF EACH OF THE IDENTIFICATION DOCUMENTS OF WHICH COPIES ARE ATTACHED HERETO AND SIGNED BY THE MODEL.  

 

_____________________________                          Today’s Date:   _________________

Signature of Primary Witness

 

_____________________________             

Print Name of Witness

 

Copy of Depiction Attached:     Hardcopy/Digital             Internet Location/URL: http://www.melissacontest.com