STATE OF ALABAMA OFFICE OF SECRETARY OF STATE P.O. BOX 5616 MONTGOMERY, AL 36103-5616 www.sos.state.al.us BETH CHAPMAN SECRETARY OF STATE APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT (VALID FOR TWO YEARS)  Check One (Fees are non-refundable) K $200 I K $100 IB K K NITIAL APPLICATION FEE APPLICATION FEE ASED ON REGISTRATION OR LICENSE FROM ANOTHER STATE NITIAL 1 Name: Last $100 RENEWAL LICENSE FEE $100 R ENEWAL BASED ON REGISTRATION/LICENSE FROM ANOTHER STATE APPLICATION SHOULD BE TYPED OR PRINTED First Middle 2 Home Address: Street City Zip Code 3 Principle Business Address: Street City Zip Code City Zip Code 4 Name/Address of Affiliation (If applicable): 5 Your Social Security Number 000¬00¬0000 Street Your Home Telephone Number Your Business Telephone Number 6 LIST THREE (3) REFERENCES (NOT RELATED TO APPLICANT) Name Address Telephone Number Name Address Telephone Number Name Address Telephone Number American LegalNet, Inc. www.FormsWorkflow.com PAGE 2 ANSWER ALL QUESTIONS COMPLETELY 7 GENERAL Name of your Spouse: Have you ever been known by any other name or surname? Yes No Name of Spouse's Employer: If your answer is "Yes" please state all names used and when so used: (If more space is needed use reverse side.) Street Address State City Zip Code Does your Spouse have any business relationship with any professional sport or professional sports team? No Yes Your date of Birth: (Mo) (Day) Place of Birth: If you answer is "Yes" please provide details of said relationship: (City and State) (Yr) If a married woman, please state your maiden name: 8 EDUCATION: HIGH SCHOOL GRADUATE OR GED? ( )YES ( ) NO Name and location of high school attended: From (Mo) (Yr) From Name and location of Colleges and Universities Attended: (Mo) (Yr) From Name and location of Law or Other Graduate School Attended: 9 EMPLOYMENT: (Check one) I am currently (Mo) (Yr) Employed To Did you Graduate? Date of Graduation To Did you Graduate? Degree and Date To Did you Graduate? Degree and Date (Mo) (Yr) (Mo) (Yr) (Mo) (Yr) Self-Employed Name and Address of Employer: If Self-Employed complete the following: Name Name Street Address Street Address City State Zip Code City Zip Code State Nature of Business: Telephone No. Nature of Business Your Title/Position Starting Date Starting Date (Last 5 years immediately preceding date of application. Use additional sheets as necessary) Œ Name of Previous Employer: Your Title/Position  Name of Previous Employer: (Last 5 years immediately preceding date of application. Use additional sheets as necessary) Employer Employer Street Address Telephone No. City State Start Date Ending Date Zip Code Street Address Your Title/Position City State Zip Code State Date Ending Date American LegalNet, Inc. www.FormsWorkflow.com PAGE 3 10 BUSINESS/CORPORATION: If a corporation employs you as an athlete agent then provide the names and addresses of the officers, directors, and any shareholders of the corporation having an interest of five percent (5%) or greater. (Use additional sheets if necessary) If your business as an athlete agent is not a corporation then provide the names and addresses of all partners, members, officers, managers, associates or profit-sharers of the business. (Use additional sheets if necessary) (Name) (Address) (Name) (Address) (Name) (Address) (Name) (Address) 11 Have you or any person named in question #10 above ever been convicted of a crime that, if committed in this state, would be a crime involving moral turpitude or a felony? ¨ Yes ¨ No If "Yes" then identify the crime:________________________________________________ 12 Has there ever been a judicial or administrative determination that you or any person named in question #10 above has made a false, misleading, deceptive, or fraudulent representation? ¨ Yes ¨ No 13 Has your conduct or that of any person named in question #10 above ever resulted in the imposition of a sanction, suspension, or declaration of ineligibility to participate in an interscholastic or intercollegiate athletic event on a student-athlete or educational institution? ¨ Yes ¨ No 14 Has there ever been a sanction, suspension, or disciplinary action taken against you or any person named in question #10 above arising out of occupational or professional conduct? ¨ Yes ¨ No 15 Has there ever been any denial of an application for, or suspension or revocation of, or the refusal to renew 11 16 the registration or licensure of yourself, or any person who is named in question #10 above as an athlete agent ¨ Yes in any state? ¨ No PRACTICAL EXERIENCE/FORMAL TRAINING AS ATHLETIC AGENT: Provide in detail a description of your formal training, practial experience, and educational background relating to your professional activities as an athletic agent: (attach additional sheets if necessary) American LegalNet, Inc. www.FormsWorkflow.com PAGE 4 17 PROFESSIONAL SPORTS EXPERIENCE: List the name, sport and last known team for each individual for whom you have acted as an athlete agent during the five (5) years preceding the submission of this application: (Name of Athlete) 18 (Professional Sports Team) (Sport) OATH/AFFIRMATION In submitting this application for registration as an athlete agent in the state of Alabama, I do hereby swear or affirm that I have reviewed the information contained herein and on any attachments hereto, and that such information is correct and true to the best of my knowledge. I understand that giving false information in this application constitutes cause for denial or revocation of my application and could subject me to criminal prosecution for perjury. I acknowledge that I have a duty and I agree to update and correct this information as it changes. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification, my application could be rejected or my registration revoked and that I may be subject to prosecution in the state of Alabama. Signature of Applicant State of County of ) ) Date Sworn and subscribed to before me this _____day of _____________,________. month year FOR DEPARTMENT USE ONLY Notary Public Signature My Commission Expires:____________________________ Notary Seal DATE PERMIT ISSUED PERMIT NO. American LegalNet, Inc. www.FormsWorkflow.com