Background Performer Information Form – U.S.
18 U.S.C. Section 2257 and 2257A
I understand that the information below will be collected and used for the purposes of complying with age
verification and record-keeping requirements for film and video producers pursuant to the record keeping
requirements under 18 U.S.C. § 2257 and § 2257A (“Pence Amendment”/Adam Walsh Act”).
All Performers MUST complete and sign the following. Central Casting personnel will verify the
performer’s date of birth shown on this form by examining an original piece of government-issued
identification. The identification will not be photocopied.
Performer’s Legal Name:
(include all middle names)
Full Social Security Number
Date of Birth:
I confirm the accuracy of the information listed above, and have shown government-issued identification
to production company personnel to verify my date of birth.
Performer’s Signature: _____________________________________ Date: ______________________
Central Casting or Production Representative (appointed by Central Casting) use only
Identification Used for Age & Date of Birth Verification Purposes
Type of ID:
# (if any): _________________________
Issuing Country/#: ___________________
Name & Title of Representative Verifying Date of Birth
Agent of Central Casting
CENTRAL CASTING 220 S. Flower St Burbank, CA 91502
This form must be completed and signed by every performer in the production, including background performers.
Government-issued identification must be checked (but not copied) to verify date of birth shown on this form, signed
by authorized Central Casting personnel, and then filed at the Central Casting office listed above.