PERFORMER RECORD as requested by 18 USC 2257

Performer's present and correct name:
(lastname, firstname middlename):
Performer's professional name (alias) for
use with this company's productions:
Any other names ever used by the
performer including maiden name,
aliases, nicknames, stage names,
DBAs, or professional names:

Attached to this record, or stored with this record, is a copy of a passport issued by the United States or a foreign country, a green card issued by the U.S., or driver’s license or identification card issued by a State, which bears the photograph and the name of the individual.

Complete 1 of these 3:

-Passport
Name of issuing country, and passport #:

-Driver's License
Name of issuing U.S. state, and i.d.#:

-State Photo I.D.
Name of issuing U.S. state, and i.d.#:

-U.S. Green Card
Identification #:
Performer's Present Age:
Performer's Date of Birth:
Date Performer's I.D. was examined:
Performer's I.D. was examined by (name):

Depictions of this performer are published in/on the following Works:

WEBSITE URLS:
VIDEO TITLES OR
VIDEO IDENTIFYING NUMBERS: