ADULT MODEL RELEASE: 2257 COMPLIANT FORM:
Model Legal name: _____________________________________
Stage Name :( if any) ___________________________________
Maiden Name: ________________________________________
Previous Legal Name :( if any) ____________________________
If model has additional other names must include:____________________________
Date of Birth: ________/____/_______ Age: _______
() D.L NUMBER: __________________ State: __________
() USA Passport: ________________
() Social Security: ______ ___ _____
() OTHER: ____________________
Address: ____________________ Apt:______ City:__________ State:______
Zip Code:________
Cell Phone :( ) ______-______ Home Phone :( ) ______-______
DATE OF PHOTOSHOOT: _____/_____/______
Model signature: ___________________________
Print name of Model: _______________________
Model understands that all the information given in this agreement is being to comply with FEDERAL LAW and any false statement will subject MODEL to both a civil action by PHOTOGRAPHER as well as criminal prosecution under federal
and state law_______________
(Model’s initials)
SWORN STATEMENT: UNDER 28 U.S.C.1746 AND THE PENALTIES OF PERJURY UNDER THE LAWS OF THE UNITED STATES, I SWEAR THAT THE FOREGOING IS TRUE AND CORRECT AND THAT EACH OF THE IDENTIFICATION DOCUMENTS WHICH I HAVE PROVIDED AND OF WHICH I HAVE SIGNED THE ATTACHED COPY WAS LAWFULLY OBTAINED BY ME AND HAS NOT BEEN GORGED OR ALTERED.
DATE ON:_______/___/________
Model signature: ___________________________
Print name of Model: ________________________
UNDER 28U.S.C 1746 AND THE PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES I SWEAR THAT THE FOREGOING IS TRUE AND CORRECT, THAT I HAVE PERSONALLY EXAMINED THE MODEL OR ACTRESS PHOTO IDENTIFICATION AND DATE OF BIRTH, AND THAT I HAVE OBSERVED THE ORIGINALS OF EACH OF THE IDENTIFICATION DOCUMENTS OF WHICH COPIES ARE ATTACHED HERE TO SIGNED BY THE MODEL OR ACTRESS.IN ADDITION I SWEAR THAT THE DATE SET FORTH BELOW IS THE DATE ON WHICH PHOTOSHOOT OCCURRED.
DATE ON: _______/___/_____
Photographer signature: _______________
TERMS AND CONDITIONS:
I, the undersigned model (hereafter model) do hereby voluntarily authorize and give permission to Undying Xpressionz or their assigns (hereafter Photographer) to the exclusive use of: photographs, video, electronic and digital reproductions in any form of my person or personal property. From the date of execution of this General Release and Authorization, the undersigned hereto does hereby grant, release and assign to Undying Xpressionz any and all claims of right whatsoever in and to all photographs or printed materials of the undersigned or by the undersigned and delivered to Photographer for any purpose chosen by Photographer. From execution hereto and for value received and acknowledged below by model Photographer shall exclusively and irrevocably own in perpetuity all right, title and interest, including copyright, in and to the digitized photographs, reproductions, video and any digitized printed material of the undersigned with no rights expressly reserved by the model.
Model also grants Photographer and its designees the right to use his/her name, likeness, image voice, appearance, and performance as embodied in the Product whether recorded on or transferred to videotape, film, slides, photographs, audio tapes, or other media, now known or later developed.
This grant includes without limitation the right to edit, mix or duplicate and to use or re-use the Product in whole or part as Photographer may elect. Photographer or its designee shall have complete ownership of the Product in which model appears, including copyright interests, and model acknowledges that she has no interest or ownership in the Product or its copyright. Model also confirms that she/he has the right to enter into this Agreement, that she/he is not restricted by any commitments to any
parties, and that Photographer has no financial commitment or obligations to me as a result of this Agreement besides the consideration already paid.
I hereby give all clearances, copyright and otherwise, for use of my name likeness, image voice, appearance and performance embodied in the Product. I expressly release and indemnify Photographer and its officers, employees, agents and designees from any and all claims known and unknown arising out of or in any way connected with the above granted uses and representations. The rights granted Photographer herein are perpetual and worldwide survive my death and any other occurrence.
In consideration of all the above, I hereby acknowledge receipt of reasonable and fair consideration from the Photographer received and paid.
Undying Xpressionz agrees to pay Model the base compensation of $ ________
Model initials: ________
I the above-signed model do hereby certify and swear under unsworn declaration of perjury that the following is true and correct by my above signature and that I agree with such terms.
( ) I swear that I am above 18 years of age
( ) I swear that I have disclosed my correct legal name
() I swear that I have disclosed all other names that I have been known by to Photographer
() I swear that I have produced a legal identification card
() I swear that I have not provided any false or misleading information to Photographer
() I swear that I will do nothing in violation of any local, State or Federal laws
Including any obscene, lewd or illegal act.
( )I swear that I will not bring unto Company’s premises or where Photo shoot is occurring drugs, alcohol or other illegal substances.
DATE OF PHOTOSHOOT: ________________
MODEL: _____________________
PHOTOGRAPHER: __________________________
