Title 18 USC 2257 Required Identity and Age Verification Form Please ensure the text size is set to medium in Internet explorer before printing this page!
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Today's Date:Month:_________Day: ______Year:_______
I__________________________________  do hereby affirm that the following information is true and correct and ALL names (maiden names, married names, nicknames, stagenames, professional names, aliases, screennames, etc...) that I have previously used are listed below. Please print clearly, and the signature cannot be typed.
Full Name:  First _____________________ Middle:____________ Last:____________________
Date Of Birth: Month:____________ Day:______________ Year: ________________
Birth Name:____________________________________________________________
Maiden Name: _________________________________________________________
Married Name(s): ______________________________________________________
Nickname(s):__________________________________________________________
Professional Name(s):__________________________________________________
Stage Name- Option 1:_________________ Option 2:________________Option 3: __________________
Alias(s):_____________________________________________________________
_______________________________	_______________________________
(Performer's Real Name)	(Identification Type)
_______________________________	_______________________________
(Performer's Signature)	(Identification Number)