Background Performer Information Form printable pdf download

Background Performer Information Form

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:

______/______/_________

YYYY

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

Driver’s License

Other

State/#: ____________________

Type of ID:

_________________________

Passport

# (if any): _________________________

Issuing Country/#: ___________________

Name & Title of Representative Verifying Date of Birth

Name:

Title:

Agent of Central Casting

Signature:

Company:

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.

CENTRAL CASTING™2014

Background Performer Information Form