State of California Secretary of State Athlete Agent Disclosure Statement A $30.00 filing fee must accompany this form. IMPORTANT - Read instructions before completing this form. Filing of false, misleading, or incomplete statements on this form may subject you to criminal and civil penalties under the Miller-Ayala Athlete Agents Act, Chapter 2.5 (commencing with Section 18895) of Division 8 of the Business and Professions Code. 1. Individual Entity File No. ______________________ This Space for Filing Use Only 2. Name of Athlete Agent 3. Street address of all locations where business is to be conducted, including City, State, and Zip Code (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ 4. Name of designated agent for service of process in California 5. Street address of designated agent for service of process in California City State CA Zip Code 6. List all businesses and/or occupations engaged in for the two years preceding the date of this filing (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ CHECK YES OR NO TO QUESTIONS 7 THROUGH 11. YES 7. Has the athlete agent ever been convicted of a felony? 8. Has the athlete agent ever been convicted of a misdemeanor involving a violation of Chapter 2.5 of Division 8 of the Business and Professions Code, or Chapter 1 (commencing with Section 1500) of Part 6 of Division 2 of the Labor Code as repealed by Chapter 857 of the Statutes of 1996, or the law of any other state governing athlete agents? 9. Has the athlete agent ever been convicted of fraud, theft, embezzlement, fraudulent conversion, or misappropriation of property? 10. Has the athlete agent ever made any appearances before any disciplinary or professional board, association, secretary, committee, or other entity as a result of disciplinary charges or other allegations of misconduct against the athlete agent? If yes, explain the outcome of those proceedings (attach additional pages if necessary). 11. Has any student athlete or any educational institution been sanctioned, suspended, or declared ineligible to participate in one or more interscholastic or intercollegiate athletic events in any proceeding arising from, or related to, the actions of this athlete agent? NO COMPLETE EITHER 12 OR 13 OR BOTH, WHICHEVER IS APPROPRIATE: 12. Name the insurer and amount of coverage for the security required by Business and Professions Code section 18897.87(a) 13. Specify the type, value and specific location of security consistent with the requirements of Business and Professions Code section 18897.87(b) SEC/STATE SFAA Rev 04/2015 (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com FILING FEE: $30.00 14. List all past and present persons on behalf of whom the athlete agent has acted as an athlete agent (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ 15. List the names of any players' associations with whom the athlete agent is registered (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ 16. List at least three references with complete addresses and phone numbers (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ 17. List all affidavits or certificates of completion of any and all formal training or practical experience in any of the following specific areas: contracts, contract negotiation, complaint resolution, arbitration, or civil resolution of contract disputes (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ 18. List the name and residential address of all persons financially interested in the operation of the business of the athlete agent, whether as employees, partners, investors, associates, or profit sharers, or in any other manner (attach additional pages if necessary) A._____________________________________________________________________________________________________________________ B._____________________________________________________________________________________________________________________ C._____________________________________________________________________________________________________________________ 19. Attach a schedule of fees to be charged and collected in the conduct of the athlete agent business. SECTION 20A THROUGH 20C APPLICABLE ONLY IF THE ATHLETE AGENT IS AN INDIVIDUAL 20. A. Residence address of Athlete Agent City State Zip Code B. Social Security Number of Athlete Agent C. Driver's License Number of Athlete Agent 21. I declare that this disclosure statement is true, correct and