Ø ooz 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 American LegalNet, Inc. www.FormsWorkflow.com Ø oo¡ UCONN COMPLIANCE DATES OF REPRESENTATION t. 2. 3. 4. 5. 6. 7. 8. 9. 10. PLEASEPLACEANT6*',BEFoREA}TYATI{LETE,SNAMETIIATMAYBECoNTACTED. American LegalNet, Inc. www.FormsWorkflow.com @oot 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) American LegalNet, Inc. www.FormsWorkflow.com @ oos 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: American LegalNet, Inc. www.FormsWorkflow.com Ø ooe 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: American LegalNet, Inc. www.FormsWorkflow.com Ø ooz 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? American LegalNet, Inc. www.FormsWorkflow.com . c. Are you a Ø ooe 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 American LegalNet, Inc. www.FormsWorkflow.com ø ooe 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 American LegalNet, Inc. www.FormsWorkflow.com