Batt Industries, LLC 901 S. Roosevelt Street Tempe, Arizona 85281 ph. 480.217.0625

Project Session Title:__________________________________________________

Session Manager:____________________________________________________

Photographer:_______________________________________________________

Date of Session:_____________________________________________________

Model/Actor Indentifying Information and Affidavit -

Model/Actor understands that all the information given in this Agreement is being provided to comply with federal law, any false statement will subject Model/Actor to both civil action by Batt Industries, LLC, as well as criminal prosecution under federal and state law. Please print legibly.

Full Legal Name:______________________________________________________

Date of Birth:_________________________________________________________

Place of Birth:________________________________________________________

Form of Identification: Must be a government-issued photo I.D. (photocopy filed with us).

Description of I.D.

___________________________________________________________________

Height:_________Weight:___________Eye Color:_________ Hair Color:_________

Social Security #:__________________ Phone:___________ Email:_____________

Address:__________________________________________Suite:_____________

City:__________________State:____________Zip:__________________________

Web Site Address:____________________________________________________

UNDER THE PENALTY OF PERJURY OF THIS STATE, I SWEAR THAT THE FOREGOING IS TRUE AND CORRECT, AND THAT EACH OF THE INDENTFICATION DOCUMENTS WHICH I HAVE PROVIDED AND WHICH I HAVE SIGNED THE ATTACHED COPY WAS LAWFULLY OBTAINED BY ME AND HAS NOT BEEN FORGED OR ALTERED.