IDAHO STATE ATHLETE AGENT REGISTRATION BUREAU OF OCCUPATIONAL LICENSES 700 West State Street, P.O. Box 83720 Boise, Idaho 83720-0063 Phone: (208) 334-3233 Fax: (208) 334-3945 Website: www.ibol.idaho.gov E-mail: aag@ibol.idaho.gov APPLICATION FOR REGISTRATION NOTICE There are specific requirements and prohibitions governing the practice of athlete agents in Idaho. Please review the Revised Uniform Athlete Agents Act, Idaho Code � 4801 et seq., prior to submitting your application. Violation of the Revised Uniform Athlete Agents Act shall constitute a criminal misdemeanor. The Bureau may assess a civil penalty against an athlete agent not to exceed twenty-five thousand dollars ($25,000), in addition to any criminal penalties or civil remedies, for a violation of this chapter. INSTRUCTIONS All requested information must be provided and all questions must be answered accurately and in full; use a separate sheet if needed to answer any question(s). Should additional information be required from 3rd party sources, you may be required to request that information and have it sent directly from the 3rd party to the Bureau. Your application will not be processed until all required information and documentation is received. APPLICATION CHECKLIST Incomplete applications will delay the processing of your application. All returned checks are subject to a $20.00 fee. Application based only on Idaho Application � Application and Registration Fee: $250 � Section I of Application � Section II of Application � Separate sheets needed for explanations � Section IV of Application Application based on Reciprocal Registration � Application and Registration Fee: $250 � Section I of Application � Section III of Application � Separate sheets needed for explanations � Section IV of Application � Copy of your current registration as an athlete agent in another state � Copy of original application for registration as an athlete agent in another state Questions regarding this application or the requirements for licensure may be addressed to the Bureau of Occupational Licenses at the contact information above. BOL-AAG-1 7/16 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com IDAHO STATE ATHLETE AGENT REGISTRATION BUREAU OF OCCUPATIONAL LICENSES 700 West State Street, P.O. Box 83720 Boise, Idaho 83720-0063 Phone: (208) 334-3233 Fax: (208) 334-3945 Website: www.ibol.idaho.gov E-mail: aag@ibol.idaho.gov APPLICATION FOR REGISTRATION Please review the attached instructions. Complete this form by providing the requested information (please print). Your signature must be notarized and the appropriate fees must be attached. Submit the completed form to the address noted above. I hereby apply to register and practice as an Athlete Agent in the State of Idaho under Title 54, Chapter 48, Idaho Code, as amended, by: (please check applicable box) [ ] Idaho Application (complete Sections I, II, & IV) [ ] Reciprocal Registration (complete Sections I, III, & IV) SECTION I � All applicants 1. Full Name _____________________________________________________________________________________ 2. Date of Birth ______/____/_______ S.S. No. _____/____/______ month day year Place of Birth_________________________ (not a public record; collected per I.C. � 73-122) 3. Work and Mobile Phone Numbers ________________________________________________________________ 4. Fax___________________________________________________________________________________________ 5. Email_________________________________________________________________________________________ 6. Principal Place of Business Address________________________________________________________________ Address City State Zip SECTION II � Idaho Application only Complete this section if you are applying for registration based only on this application. 1. Personal and Business Websites __________________________________________________________________ ____________________________________________________________________________ 2. Social Media Accounts__________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. All Business or Employer Names (if any) (use a separate sheet if needed)_________________________________ ________________________________________________________________________________________________ 4. For each business or employer identified in question 3, please provide the Mailing Address (use a separate sheet if needed) ________________________________________________________________________________________ 5. For each business or employer identified in question 3, please provide the Email Address (use a separate sheet if needed) __________________________________________________________________________________________ 6. For each business or employer identified in question 3, please provide the Telephone Number (use a separate sheet if needed) ____________________________________________________________________________________ BOL-AAG-1 7/16 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 7. For each business or employer identified in question 3, please provide the Type of Business Organization/Nature of the Business (use a separate sheet if needed) _________________________________________________________________________________________________ 8. Please describe the business or occupation you have engaged in for the five years preceding the date of this application, and list any professional or occupational licenses, registrations, or certificates held during that time: _________________________________________________________________________________________________ _________________________________________________________________________________________________ 9. Do you have formal training as an athlete agent? (If yes, please describe, use a separate sheet if needed.) [ ]Yes [ ] No __________________________________________________________________________________________________ __________________________________________________________________________________________________ 10. Do you have practical experience as an athlete agent? (If yes, please describe, use a separate sheet if needed.) [ ]Yes [ ] No __________________________________________________________________________________________________ ________________________________________________________________________________