Virginia Tech AGENT REGISTRATION FORM The completion of this form in its entirety is required for registration in the Virginia Tech Student-Athlete Agent Program. [PLEASE PRINT OR TYPE] I) GENERAL INFORMATION Name:_________________________________________ SS#:_______________________ Date of Birth:_________________ Phone: (___)_________________ Home Address:__________________________________________________________________ City State Zip If affiliated with a particular firm or agency, please indicate: Name of Firm/Agency:_____________________________________________________ Business Address:________________________________________________________ ______________________________________________(____)__________ City II) State Zip Business Phone PROFESSIONAL SERVICES General services performed for client-athletes (check those that apply and indicate fee charged): Playing Contract Negotiations: _____ Yes Endorsement Contract Negotiations: _____ ______ ______ Yes Tax Consulting: ______ No _____ ______ Yes Financial Planning: _____ No _____ Yes Money Management: Percentage or Hourly Fee: ______________ No Yes Legal Assistance: Percentage or Hourly Fee: ______________ No _____ Yes ______ Percentage or Hourly Fee: ______________ Percentage or Hourly Fee: ______________ Percentage or Hourly Fee: ______________ No ______ Percentage or Hourly Fee: ______________ No American LegalNet, Inc. www.FormsWorkFlow.com If any other individuals, firms or agencies assist you in providing these services for clientathletes, please list their names and addresses: ___________________________________________________________________ Name City State ___________________________________________________________________ Name City State ___________________________________________________________________ Name City State Please list the names of athletes that you previously represented or currently represent. For those athletes involved in team sports, please list the team/league to which each athlete is currently under contract. Write "none" if you currently do not represent any athletes. If you represent athletes in more than one sport, please provide information for at least three clients (athletes) in each sport. Use additional sheets as necessary. Player's Name Team Client's Phone # ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ III) EXPERIENCE Number of years experience as an agent/representative: ________________ Please list the sports in which you currently represent athletes, and the total number of athletes in each sport: ______________________________ _____ ______________________________ _____ ______________________________ _____ ______________________________ _____ 2 American LegalNet, Inc. www.FormsWorkFlow.com IV) EDUCATION High School Name:___________________________________________________________ City State College (Undergraduate) School Name:______________________________________________________ City State Degree(s) and Year Graduated:________________________________ Graduate/Legal College/University:_________________________________________ Admitted to Bar (If applicable) Yes_______ No________ ___________ ________________ State V) Date Admitted to Bar OTHER QUALIFICATIONS Current membership in professional organizations: __________________________________ _______________________________________________________________________________ Occupational or professional licenses (certified public accountant, chartered life underwriter, etc.) and date obtained: ________________________________________________ ________________________________________________________________________________ Are you currently registered with any other state as an agent/representative? _____ _____ Yes Are you currently certified by the NFLPA? _____ Yes _____ No Permanent No Provisional (Circle One) If no, please explain why: __________________________________________________________ _______________________________________________________________________________ Are you currently certified by the NBPA? _____ Yes Are you currently certified by the MLBPA? _____ Yes _____ No _____ No Permanent Provisional (Circle One) Permanent Provisional (Circle One) 3 American LegalNet, Inc. www.FormsWorkFlow.com Do you earn income from work performed in some capacity other than as an agent/representative? ______ ______ Yes No If yes, describe other occupation(s) or service(s) for which you are paid: ________________________________________________________________________ ________________________________________________________________________ VI) PREVIOUS EMPLOYMENT (last two positions and dates of employment) Firm:___________________________ Position/Date:______________________ Address:________________________________________________________________ City Firm:___________________________ State Zip Position/Date:______________________ Address:________________________________________________________________ City VII) State Zip PROFESSIONAL REFERENCES Name:__________________________ Position:________________________ Address:________________________________________________________________ City Name:__________________________ State Zip Position:________________________ Address:________________________________________________________________ City Name:__________________________ State Zip Position:________________________ Address:________________________________________________________________ City State Zip 4 American LegalNet, Inc. www.FormsWorkFlow.com Please indicate which current Virginia Tech student-athlete(s) you plan to contact: _______________________________________ ____________________________________ _______________________________________ ____________________________________ _______________________________________ ____________________________________ _______________________________________ ____________________________________ I certify that the above information is true, correct and complete to the best of my knowledge. Further, I certify that I will notify Shauna Cobb, Assistant Director of Athletics for Compliance, before my first contact with any student-athlete who has eligibility remaining and is enrolled at Virginia Tech. In addition, I have reviewed the NCAA regulations regarding agents, as well as the policies and procedures contained in the Virginia Tech Student-Athlete Agent Program. I have not engaged in any activity or behavior that would jeopardize a student-athlete’s collegiate eligibility. I certify that I will comply with the policies of the Virginia Tech Student-Athlete Agent Program and all applicable NCAA legislation. I understand that failure to do so will result in the initiation of proceedings to disassociate me from Virginia Tech, as well as prevent any other person(s) representing my firm or company from contacting Virginia Tech student-athletes in the future. Signature:_______________________________________ Date:_____________________ Please Return Completed Form to: Bert Locklin Director of Athletics Compliance Virginia Tech 356 Jamerson Athletic Center Blacksburg, VA 24061 American LegalNet, Inc. www.FormsWorkFlow.com