ATH, Rev 9/09 For Official Use Only STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION Occupational & Professional Trades Division Telephone: (860) 713-6155 Website: www.ct.gov/dcp REGISTRATION FOR AGENT FOR STUDENT ATHLETES INSTRUCTIONS: This form must be completed by the individual applying for registration and accompanied by: • • • A check or money order in the amount of $250.00, made payable to: “Treasurer, State of Connecticut.” Three (3) letters of reference. A resume detailing your education, formal training, and/or practical experience in contracts, contract negotiation, complaint resolution, arbitration, civil resolution of contract disputes, and/or experience as a professional athlete. For Corporations, Companies and Legal Entity Applicants: • Provide a listing of each person acting as an athlete agent. Each person must submit a registration form for agent of student athlete. • Attach a list of all Officers, Partners or Members of the legal entity, their home addresses and telephone numbers. Return your completed application and registration fee to: Department of Consumer Protection, License Services Division, 165 Capitol Avenue, Hartford, CT 06106 Please check ( ) the type of license applying for: INDIVIDUAL CORPORATION LIMITED LIABILITY COMPANY PARTNERSHIP INDIVIDUAL WORKING FOR A CORPORATION, LLC OR PARTNERSHIP Applicant’s Name Street Address Social Security or FEIN Number City Date of Birth or Incorporation State Zip Code Telephone Number (with area code) List all Businesses that You (or your Business) have Owned, Had a Financial Interest In, and/or have been Employed by within the Last Three Years. List Current Business First. Company Name Address Your Title Nature of Business Company Name Address Your Title Nature of Business Please list the Names of Each Company in which You, Your Spouse, and/or Your Minor Children Own Stock of at least 5% of the outstanding shares _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Please answer the following. Attach additional sheets if necessary. Have you ever been convicted of a crime excluding misdemeanor motor vehicle offenses? YES NO If YES, please state each offense and date of conviction. Are you an attorney at law admitted to practice in the State of Connecticut? YES NO If YES, please state your Juris Number ____________________________________________ Have you ever been disciplined? YES NO If YES, please state each incident Are you a certified accountant admitted to practice in the State of Connecticut? YES NO If YES, please state your License Number ____________________________________________ Have you ever been disciplined? YES NO If YES, please state each incident, date, and issuing authority on a separate sheet Have you ever had any license or registration revoked or suspended by any licensing authority? YES NO If YES, please state each incident, date, and issuing authority on a separate sheet Do you currently hold or did you ever hold any license or registration issued by the Department of Consumer Protection? YES NO If YES, please give each license /registration number __________________________________________________ Do you currently hold or did you ever hold any registration as a sports agent issued by any other issuing authority? YES NO If YES, please give registration number and issuing authority ___________________________________________ If Yes, please provide the names of the athletes currently under your or your company’s agency management. _____________________________________________________________________________________________________________________ If you claim that this information is proprietary, please list the information on a separate sheet headed, “Privilege Claimed”. Has any athlete, while under your or your company’s management, ever filed a claim against you or your company? YES NO If YES, please state each claim and disposition _____________________________________________________________ Any persons making any misstatement as to experience or other qualifications or any person subscribing to or vouching for any misstatement shall be subject to those penalties as provided for in the Connecticut General Statutes. I subscribe and affirm under the penalties of perjury, that the statements made in this application have been examined by me and to the best of my knowledge and belief are true and correct. ____________________________________________________________________ Signature and Title of Applicant ______________________ Date Subscribed and Sworn to before me, this _______ day of ____________________ 20______ ___________________________________________________ Notary Public/Commissioner of the Superior Court __________________ My Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com