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Production/Movie Name

Type of Production

Name of Business/Production Company

Federal ID Number

Phone Number

Business Address

City

State

Zip Code

County

Workers' Compensation Insurer

Policy Number

Legal Name of Minor

Last 4 Digits of SSN

Birth Date

Minor's Address

City

State

Zip Code

Description of Role/Activity to be Performed

Onsite Business/Production Company Name

Federal Tax ID Number

Phone Number

Onsite Address

City

State

Zip Code

Contact Person Name

Contact Person Address

City

State

Zip Code