North Carolina Department of the Secretary of State ATHLETE AGENT - COMPLAINT FORM DIRECTIONS: You may use this form to send a complaint about an athlete agent to the Athlete Agent Registration Office. While not required by law, the questions below request information that in past cases has proved helpful in determining whether a person have violated North Carolina’s Athlete Agent laws. Please attach additional pages as needed to give a full and accurate answer. Please attach copies of any documents that support your complaint. Please mail the completed form and copies of supporting documents to: Athlete Agent Registration Office - CF N.C. Department of the Secretary of State P.O. Box 29622 Raleigh, NC 27626-0622 Or fax to: (919) 807-2010 TODAY’S DATE: ______________________________ 1) What is your name and contact information? Mr./Ms./Dr. ________________________________________________________________________ Home Address: ________________________________________________________________________ ________________________________________________________________________ Work Address: ________________________________________________________________________ ________________________________________________________________________ Job Title : ________________________________________________________________________ Telephone (H): ________________________________________________________________________ Telephone (W): ________________________________________________________________________ Best time to reach you: ________________________________________________________________ E-mail Address: ________________________________________________________________ 2) Who is the individual against whom you would like to file a complaint? Name of Person: ________________________________________________________________________ 1 American LegalNet, Inc. www.USCourtForms.com Name of Employer: Address: ________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Job Title: ________________________________________________________________________ Telephone (H): ________________________________________________________________________ Telephone (W): ________________________________________________________________________ E-mail Address: ________________________________________________________________ What is your relationship to this person? __________________________________________________ 3) What is the basis for your complaint? (Check all that apply) ___ I believe this individual has entered into an agency contract with a student-athlete, but has not registered with the Department of the Secretary of State pursuant to N.C.G.S. § 78C-88. ___ I believe this individual has recruited or solicited a student-athlete to enter into an agency contract, but has not registered with the Department of the Secretary of State pursuant to N.C.G.S. § 78C-88. ___ I believe this individual has represented to the public that he or she is an athlete agent, but has not registered with the Department of the Secretary of State pursuant to N.C.G.S. § 78C-88. ___ I believe this individual intentionally falsified information in an application for registration as an athlete agent provided to the Department of the Secretary of State pursuant to N.C.G.S. § 78C-89. ___ I believe this individual is using agency contracts that are not in a format as prescribed by N.C.G.S. § 78C-94 ___ I believe this individual entered into an agency contract with a student-athlete, but did not give a record of the signed or otherwise authenticated agency contract to the studentathlete at the time of the contract’s execution as required by N.C.G.S. § 78C-94(e). ___ I believe that this individual has asked a student-athlete to waive his or her right to cancel an agency contract within fourteen days after the contract is signed in violation of N.C.G.S. § 78C-96(b). ___ I believe this individual intentionally predated or postdated an agency contract in violation of N.C.G.S. § 78C-98(5). ___ I believe that the individual did not give notice to the athletic director of the educational institution where a student-athlete is enrolled within seventy-two hours after entering into an agency contract with that student-athlete or before the next scheduled event in which that student-athlete may participate in violation of N.C.G.S. § 78C-95. ___ I believe this individual is an athlete agent and that he or she is not maintaining records for a period of five years as required by N.C.G.S. § 78C-97. 2 American LegalNet, Inc. www.USCourtForms.com ___ I believe that the individual intends to induce a student-athlete to enter an agency contract and has ___ Given materially false or misleading information or has made a materially false promise or representation; ___ Furnished anything of a value to a student-athlete before the student-athlete entered into an agency contract; and/or ___ Furnished anything of value to any individual other than a student-athlete or another registered agent ___ I believe the individual has intentionally: ___ ___ Did not register as an athlete agent with the Department of the Secretary of State; and/or ___ ___ Initiated contact with a student-athlete without being registered as an athlete agent with the Department of the Secretary of State; Failed to notify a student-athlete before the student-athlete signed an agency contract that signing the contract makes the student-athlete ineligible to participate as a student-athlete in that sport. Other. (Please specify) __________________________________________________ __________________________________________________ 4) Describe the basis of your complaint in as much detail as you are able to provide. Include dates, names and contact information for any witnesses or people with information about your complaint, and any other relevant information. Attach copies of any other documents that support your complaint to this form. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 3 American LegalNet, Inc. www.USCourtForms.com ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 4 American LegalNet, Inc. www.USCourtForms.com