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University Of Connecticut Athlete Agent Registration Form. This is a Connecticut form and can be use in Department Of Consumer Protection Statewide.
Tags: University Of Connecticut Athlete Agent Registration, Connecticut Statewide, Department Of Consumer Protection
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UCONN COMPLIANCE
FORM
UNIVERSITY OF CONI{ECTICUT REGISTRATION
AS A}[ AGENT FOR STUDENT.ATHLETES
AT THE UNWERSITY O['CONIìIECTICUT
(Social SecwitY Number)
(Full Name)
(Business Name
& Street Address)
(Fax Number)
(Telephone Number)
(City, State, Zip)
the purpose of potentially
hereby register with the university of connecticut as an agent for
1
representing University of Connecticut student-athletes'
I ask that my answers
to this questionnaire, and my ansrwers to the questions found in any
with a player's association,
and all of my applications for certification as a contract advisor filed
this registration. I recognize that making false or misleading statements
be considered as part of
in this registration may lead to a revocation of my registration.
I
this registration
also agree that all statements, agreements, and representations made in
are made for the benefit of the University
of Connecticut and its student-athletes both presørt
of Connecticut to
and future, and that the information herein may be provided by the University
its
student-atbletes, as
request
well as to other colleges/universities and their
it. I further agree to list ten (10) clients I have represented
student-athletes who
over the past three (3) years'
please piace an + next to those narnes that you authorize the'University of Connecticut (and other
colleges/universities and their student-athletes) to contact
in regard to your character, your
ten,
performance, your services, etc. (If the total number of your clients for this period exceeds
only your present and former clients in the sport in which you are seeking to
you need list
the sports
represent a University of Connecticut student-athlete and such additional clients in
football, basketball, baseball, oï soccer as are nec€ssary for your list to contain ten naures.)
Si
gnature
o
f
Re
of
gistrant
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UCONN COMPLIANCE
DATES OF
REPRESENTATION
t.
2.
3.
4.
5.
6.
7.
8.
9.
10.
PLEASEPLACEANT6*',BEFoREA}TYATI{LETE,SNAMETIIATMAYBECoNTACTED.
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QuE
srro NNATRE roR IE-glsrRATroN
AS AN AGENT FOR
uNwERsIrY oF
öÑùðiidui
srrmrNr-ATHLETES
General
1.
4,.
Full name of registrant:
b.
Ifyouareassociateclwithacompany'pleaselist:
lotu*t
and address)
Haveyoueverbeenlcrownbyanyothernameorsurname(includingamaiden
name)?
(Yes orNo)
when used:
yes, state all naÍIes used and
If
d.
2.
e. BirthPlace
Date of Birth
Education
&,
attended:
Law or other graduate school
(City & State)
(SchooÐ
Date of Attendance: From:
To:
Month/Yr'
Month/Yr'
Date Awarded:
Degree:
b.
Colleges or Universities attended:
1Dut"s Attended)
(Degree)
(Name)
(City & State)
(City & State)
(Dates Attended)
(Degree)
(Narne)
(cttv g state)
þates Attended)
(Deg¡ee)
(Name)
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Higþ School Attended:
(City & Søte)
(Name)
lD-rte-U.gr"eReceived)
athlete agent?
How long have you been an
4.
All Registrants
^.
If
Bar in any State?
Have you been admitted to the
(Yes orNo)
you afe admitted (also list any federal
please indicate the state or states in which
ves.
i"å.ãiä,i.ts
b.
in which vou are admitted)'
pending?
Bar admission currently
Do you have any applications for
(Yes or No)
If
and the status of the application:
yes, please state where you have applied
l..Listanyotherprofessionalcertifications(suchasCPA,CFP,etc.)or
professional licenses:
2'Listlicensingorcertifyingauthoritiesanddateslicensedorcertified:
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5.
Al1. Registrants
åi"'iii:
r' ìiLrùP!Àruvu'
Have you ever been cllsoaÜe
Haveyoueverbeendì1ba¡red'*:l¡*:1':'l'*ff;.1itrJ:îfåfi profession, or
of any other
as an attomey' a* ãä"aU"t
ãiscipiined or disqualified
office?
ã* u ttot¿tt of anY Public
(Yes or No)
Ifyes,pleased'escribeeachsuchaction'thedatesofoccunence'and'thenameand
in question:
th" ;;iltttvì*p"ti"g the action
address
"f
against you regarding your
any charges or complaints cunentlypending
Are
of public
orunv ptor?'J*' oi as a holder
as an attorn'ï, ã"ã*"*uo
)'
conduct
nature of the
b.
ôct-:äî;;^
offrce?
charge or complaint
äitit' pr:*e
.,ru #"n;;. ;;ä ;åit.J-ïrtnr
indicate.the
authoritv considering it:
profession or occupation
or to engage in any other
Has your right to practice law
withdraw' denied' or
ever been disqualifieà, suspended'
terminated?
(Yes or No)
ifn"ïr-r"*;æi"*
d.
n'tln
Haveyoueverbeenconvictedorpledgurltytoacriminalcharge,otherthatminor
-""]'* "^
",
yes-' please indicate
1Íes or No) If
violations?
traffic
iinvolved, and punishment
criminut authority
nature of offense, ¿atãor "onui"tion,
assessed:
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UCONN COilPLIANCE
6.
References
you for
a.Pleaselistbelowthenatnes,addresses,andtelephonenumbersofthreepersons'.
i" úusirys.slviifr you, who have known
not related to you and not fi"*U
can attest to your character'
at least the last three years uti¿irto
b.Pleaselistbelowthenames,addressesnandtelephonenumbersofatleasttwo
credit:
entities which can attest to your financial
7.
Other Qualifications
a.AreyouregisteredwiththestateofConnecticutDepartmentofConsumer
(Yes orNo)
Protectioni-
b.
(Yes or No)
c.
Are you currently certified by the NBAPA?
(Yes or No)
d.
8.
A¡e you currently certified by the NFLPA?
P errnanent or Provisional?
Are you currently certified by tle MLBPA?
card)
iuiát, pr""se enclose u "opy of your certification
(Yes or No)
Professional Services
a.
Do You handle PlaYers' funds?
Ifso,
are Yòubonded?
(Yes or No)
(Yes or No)
Ifyes,pleaseprovidedetailsastotheamountofthebond,thenameandaddress
of the surety or bonding company, etc':
b,
pa'rnent in advance, oï are
y"* p;;;";;iét"i".O
ervices' do You receive
as the player is compensated?
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.
c.
Are you
a
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UCONN COMPLIANCE
(S'E'C')?
REGISTERED INVESTMENT ADVISOR
Date Registered
(Yes or No)
d.
addition to contract
please indicate what services you offer to athletes, in
negotiation services
fee or percentage
Playing contract negotiations- Hourly
Endorsement contract negotiations
Legalassistance
--
Hourly fee or percentãge
Financial planning
Tax consultin g
Money Management
-
-
Other
e.Doyouearnincomefromworkperformedinsomeoapacityotherthanasa
or No)
student-athleteiagent?
(Yes
Ifyes,describeotheroccttpation(s)orservice(s)forwhichyouarepaid:
Whatapproximatepercentageofyourtotalworktimeisconsumedasastudentathleteiagent?
f,Previousemploymetrt(lasttwopositionsanddatesofemployment)
Position date
Fírm
Address
Position date
Firm
Addtess
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UCONN COMPLI,{NCB
References (Previous Employment)
Position
Name
Address
Position
Name
Address
Position
Name
Address
complete to the best of my knowledge'
that the above information is true, correct,and.
Marielle
*iiLo notification tó the Compliance Office' who has
Furrher, I cefify that I will provid,
rrefore the first oontact with a student-athlete
vanGelder no less than seven (7) days
the
in the University of Connecticut or before
eligibilify remaining t- *y *po.t *¿ i, .*áft'd
to provide
I also understand tl?t F -:9tt-t:lt:,"
fîrst contaot ,with the student-athlete's "o"À.
is also applicable to my associates' agents'
written and timely rroti"" to the Cornpliance Office
Further'
to lontu"t a $udånt-athlete on my behalf'
employees or any p*ï ,tt"i*"uld b: seeking
and NCAA rules and
I have reviewed the University of C""diJ, ttut" of Connecticut to a student-athlete's
will engage in no activity prior
regUlations that accompany this form and
eligibilify' I
i"oparlile.the student-athletes
agreement to t. ,"pr"J"nt"d that would "d;Ë
terrrs of this certification and the applicable
also understand that failure to comply ;iltlh"
proceedings by the university of
NCAA legislarion may result in the ;fui." of legal
civil and/or criminal penalties to me'
Connecticut against rne and the assessment of
I certify
Signature
Date
Return the comPleted form to:
Marielle vanGelder
Assistant Director of Athletics
UniversitY o f Connecticut
Division of Athi etics, \J -l 17 3
2095 Hillside Road
Storrs, CT 06269'1773
May-07 Agentreg.doc
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