18 U.S.C § 2257 Record Keeping


v2019.10A

NOTE: THIS DOCUMENT TO BE KEPT SEPARATE FROM ALL OTHER RECORDS

A. I, the MODEL, 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 United States law.

 

B. Two forms of identification, including at least one government issued photo ID, are preferred. Describe each, including number. Clear photos/photocopies of your government ID must be uploaded or otherwise provided.

ID 1 Type

 

ID 2 Type

 

C. MODEL Information:

  Is MODEL a US citizen -OR- does MODEL have a US green card?

  (If “yes”, U.S. government-issued identification MUST be used in section “B” above.)

 

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

  1.  
  2.  
  3.  
  4.  
  5.  

MODEL’S SWORN STATEMENT: Pursuant to 28 U.S.C. § 1746 and the penalties of perjury, under the laws of the United States, I swear that the above is true and correct and that the ID(s) which I have provided was/were lawfully obtained by me and has/have not been forged or altered.

Today’s Date:

PRODUCER’S / PHOTOGRAPHER’S 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 MODEL’s ID containing the date of birth set forth above, that I have personally questioned the Model regarding the answers given in this document, and that I have observed that Model execute this document. In addition, I swear that the date set forth below is the date on which production involving this model occurred.

 

 

Name of Producer: Appeal Photography, LLC

 

SIGNATURE(S):

Leave this empty:

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Signed by David Guggenheim
Signed On: January 30, 2020

Signature Certificate
Document name: 18 U.S.C § 2257 Record Keeping
lock iconUnique Document ID: b2502b33fe27da1f541492bfe66efcb47656762a
Timestamp Audit
October 30, 2019 10:02 pm EDT18 U.S.C § 2257 Record Keeping Uploaded by David Guggenheim - david@appealphotography.com IP 68.33.21.226