Performer understands that all the information

given in this Record-Keeping Compliance Form is being provided to comply with federal law and any
false statement will subject Performer to both civil action by Producer as well as possible criminal
prosecution under federal and state laws.

(a)__________________________________________________________________________________
Legal Family/Last/Surname(s)

___________________________________________________________________________________
Legal Given/First/Middle Name(s)

(b)__________________________________________________________________________________
Date of Birth

(c) Primary identification document of Performer must be government issued photo ID such as
passport, driver’s license, motor vehicle department ID, or military ID (each should be described,
including the ID number):

_________________________________________________________________

_____________________________________________________________________

_________________________________________________________________________________

(d) ________________________________________ _______________________________________

Primary Producer Original Date of This Production

(e) All other names ever used (including 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

__________________________________________ _______________________________________
Performer Signature Date