Model Release/Primary Producer’s Compliance Statement

Courtesy of Barbara Nitke, Fetish Photographer  
Read the Interview with Barbara Nitke

I certify that I am 18 years of age or older. I authorize BARBARA NITKE to take/use photographs of me to be used in print and electronic media.


Legal Name (Please Print):____________________________________________________

Date of Birth__________________________________________

Any other names ever used, including stage or professional names, aliases, nicknames, married names, maiden names, etc.:

_______________________________________________________

_______________________________________________________

Address:_________________________________________________

City:___________________________________ State:______________ Zip:_____________

Phone:________________________ Pager or Business Phone:______________________

Photo ID Type (To be photo copied):

____Driver’s License ID #________________________________________

____State Issued Photo ID #_____________________________________

____Passport ID #_______________________________________________

____Military ID #________________________________________________

Optional Second ID #___________________________________________


When using my photo(s), please identify me as________________________________

I declare under the penalty of perjury that all of the foregoing is true and correct. Executed this ____day of___________, _____________
(day) (month) (year)

In ______________________________________________
(city and state)

Signature:____________________________________________________

Please print name:____________________________________________

~~~

Copyright 2005

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