2257 Compliance Statement

Instructions for Use:

Complete All Sections: Ensure all sections are filled out completely and accurately.
Attach ID Copy: Attach a clear copy of the performer’s government-issued ID.
Signatures Required: Both the performer and producer must sign and date the form.
Record Storage: Store this form securely at the designated business address for record storage, as specified in the form

Full Legal Name

Stage Name/Alias

Government-Issued ID Type (e.g., Driver’s License, Passport)

Birthday

Address

Phone

Identification Verification

ID Number

Issuing Authority

Copy of ID Attached

Yes

Production Details

Dropdown

Date of Production

Location of Production

Statements and Certifications

I hereby certify that I am over 18 years of age and have provided valid government-issued identification as proof.

I consent to the use of my likeness in the production described above and grant all necessary rights to the producer

I confirm that the material does not contain any simulated or actual sexually explicit conduct that is obscene or otherwise unlawful.

Signatures

Performer’s Signature

Date

Producer’s Signature

Date

Record Keeping Information

Custodian of Records Name and Title:

Company: Rebel Nation Media and Broadcasting

Owner/Custodian: Joe Lawson

Business Address for Record Storage:

7504 S Fern Ave Broken Arrow, Ok 74011

Photo ID, must be a current State Issued ID with the seal of your state. No Personal ID's or SS Cards will NOT be allowed.

Attach ID Front

Attach ID Back

Create a 30-60 sec introduction video. State your legal name, and stage name if applicable. Show your State Issued ID in the shot, do not hide your face. ID needs to be unobstructed should be able to see name, date of birth and picture.

Introduction Video

Privacy Disclaimer

Rebel Nation is committed to protecting the privacy of all performers and individuals associated with our productions. The personal information collected and maintained as part of our compliance with 18 U.S.C. § 2257, including identification documents and personal details, will be used solely for the purpose of verifying age and maintaining required records.

No Sale or Transfer: We assure you that no personal information gathered through this form will be sold, transferred, or disclosed to any third parties, except as required by law or authorized government officials for compliance verification purposes.
Data Security: We implement appropriate technical and organizational measures to protect your personal data from unauthorized access, use, or disclosure.

By submitting your information, you acknowledge that you have read and understood this privacy disclaimer. For any questions regarding our privacy practices, please contact us at Joe Lawson, ‪(773) 809-3535‬

business@rebelnationmedia.net. This disclaimer should be included in the form to reassure performers that their personal information is handled with care and confidentiality. It is advisable to consult with a legal professional to ensure compliance with applicable privacy laws and regulations.

Acknowledgment and Agreement

By signing this agreement, you acknowledge and agree to the following:

Age Verification
- I hereby certify that I am at least 18 years of age or older, as required by 18 U.S.C. § 2257, and have provided valid government-issued identification to verify my age.
Liability Disclaimer
- I understand and agree that Rebel Nation Media, its associates, sponsors, and affiliates are not liable for any misinformation or inaccuracies in the information I have provided.
- I release Rebel Nation Media and its associates from any claims or liabilities arising from the use of the information provided in this agreement.

Signature

Date and time

ADMINISTRATION USE ONLY BELOW

Witness/Authorized Representative Name

Witness/Authorized Representative Signature

Date and time