Secretary of State Use Only Do not write or staple in this space REGISTRATION OF ATHLETE AGENT A.R.S. § 15-1765 Arizona Secretary of State – Business Services Division th 1700 W. Washington Street, 7 Floor Phoenix, Arizona 85007 This application may be used to apply for a certificate of registration of athlete agent in the State of Arizona under A.R.S. § 15-1765. Filing Fee: $20 – Make checks or money orders payable to the: Secretary of State. Approved by: _______________________ Registration No: _____________________ NOTE: An individual who has submitted an application for and holds a certificate of registration or licensure as an athlete agent in another state may submit a copy of the application and certificate in lieu of submitting this application. The Secretary of State will accept the application and the certificate from the other state as an application for registration in this State if the application to the other state meets all of the following requirements: A. It was submitted in the other state within the six months immediately preceding the submission of the application in this State and the applicant certifies that the information contained in the application is current and correct. B. It contains information that is substantially similar to or more comprehensive than that required in an application submitted in this State. C. It was signed by the applicant under penalty of perjury. Please Print or Type 1. Applicant First Name Applicant Last Name 2. Address of the applicant’s principal place of business City State Zip Code 3. The name of the applicant's business or employer, if applicable: 4. List every business or occupation engaged in by the applicant for the five years immediately preceding the date of the submission of this application (attach additional sheets if necessary): 5. Describe the applicant’s training, experience, and education relating to the applicant’s activities as an athlete agent (attach additional sheets if necessary): (a) Formal training as an athlete agent: 6. (b) Practical experience as an athlete agent: (c) Educational background relating to the applicant's activities as an athlete agent: List the names and addresses of three individuals who are not related to the applicant and who are willing to serve as references for the applicant: Name Name Name Address Address Address City City City State 7. Zip State Zip State Zip List the name, sport and last known team of each individual for whom the applicant has acted as an athlete agent during the five years immediately preceding the date of the submission of this application (attach additional sheets if necessary): Athlete Agent Rev. 03/09 1 Arizona Secretary of State Ken Bennett American LegalNet, Inc. www.FormsWorkflow.com 8. 9. Disclosure of associations: (a) If the applicant’s business is NOT a corporation, list the partners, members, officers, managers, associates or profit sharers of the business (attach additional sheets if necessary): (b) If the applicant is employed by a corporation, list the officers, the directors and any shareholder of the corporation that has an ownership interest of five per cent or more in the corporation (attach additional sheets if necessary): Has the applicant or any person listed in section 8 above been convicted of a crime that, if committed in this State, would be a crime involving moral turpitude or a felony? If yes, list each specific criminal conviction (attach additional sheets if necessary): Yes No 10. Has there been any administrative or judicial determination that the applicant or any person listed in section 8 above has made a false, misleading, deceptive or fraudulent representation? If yes, list each specific determination, the court or administrative body that made each determination, and the date of each determination (attach additional sheets if necessary): Yes No 11. List every instance in which the applicant’s conduct or that of any person listed in section 8 above 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 an educational institution (attach additional sheets if necessary): 12. List every sanction, suspension or disciplinary action that has been taken against the applicant or any person named in section 8 above and that arose out of occupational or professional misconduct (attach additional sheets if necessary): 13. Has there has been any denial of an application for, suspension or revocation of or refusal to renew the registration or licensure of the applicant or any person listed in section 8 above as an athlete agent in any State? If yes, please describe (attach additional sheets if necessary): Yes No I, the undersigned, being duly sworn and under the penalty of perjury, affirm and say the foregoing information provided this Application for Registration of Athlete Agent is complete, true and correct. Signature of Applicant Date Subscribed and sworn to before me this ________ day of _______________, ____________ Printed Name of Applicant Signature of Notary Public Athlete Agent Rev. 03/09 2 Arizona Secretary of State Ken Bennett American LegalNet, Inc. www.FormsWorkflow.com