Maxine X Productions, Inc., Scott Leckie (Photographe r) 2257 Compliance
(Proof o f Co mpliance with USC Title 18, Sect. 2257)
Date Form Filled In: ____________________________________________________________________
Full Legal Name of Model / Performer: _____________________________________________________
(NOT Stage Name)
Date of Birth (MM/DD/ YY): ______________________________________________________________
Provide Two Forms of Identification (Attached signed photocopies to this Release):
List Description of ID (fo r examp le: Drivers License) and ID #:
List all past and present Legal Names (such as Maiden Names and Married Names):
List all past and present Stage / Professional Names, Aliases, or Nicknames:
Under penalty of perju ry, I swear that the foregoing information provided is true and the attached copies
showing proof of Identificat ion have not been forged or altered, were lawfu lly obtained and are signed by
the Model / Performer.
Printed Name of Model / Performer: _________________ __________________Date_________________
Signature of Model / Performer: ______________________________________Date_________________
Under the penalty of perjury, I swear that the forgoing is true and correct to the best of my knowledge and
belief, and that I have observed the originals of each of the Identification documents that the Model /
Performer p rovided.
Copies of the Identification documents are attached and are signed by the Model / Performer.
Printed Name of Maxine X Productions Representative: __________________________Date___________
Maxine X Productions Representative: ____________________________________Date______________
Maxine X Producti ons, In. Form: MR-1 (03/06)