APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT Attorney General Greg Zoeller Consumer Protection Division 302 West Washington Street Indianapolis, Indiana 46204 Telephone: (800) 382-5516 (317) 232-6330 (317) 232-6201 Web site: Please type or print clearly with a blue or black pen. www.in.gov/attorneygeneral Information about Applicant 1. Type of Registration: Initial Renewal 2. Name of Athlete Agent: ______________________________________________________________________________________________ 3. Date of Birth: ______________________________________________________________________________________________ 4. Address of Principal Place of Business: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 5a. Business Phone Number: ______________________________________________________________________________________________ 5b. Business Fax Number: ______________________________________________________________________________________________ 5c. Business E-Mail address: ______________________________________________________________________________________________ 6. Name of business or employer (if any): ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Applicant’s Background and Experience 7. Please list any business(es) or occupation(s) you have engaged in for the past five (5) years: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 8. Please describe your formal training as an athlete agent: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 9. Please describe your practical experience as an athlete agent: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 10. Please describe your educational background relating to your activities as an athlete agent: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com References 11. Please list the names, addresses and phone numbers of three (3) individuals not related to you who are willing to serve as references: 1. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 2. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 3. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 12. Please list the names, sports, and last known teams for each individual for whom you have acted as an athlete agent for the last five years: Name Sport Team Business Information 13. IF YOUR BUSINESS IS NOT A CORPORATION, please list the names and addresses of all partners, members, officers, managers, associates or profit sharers of the business. IF YOUR BUSINESS IS A CORPORATION OR YOU ARE EMPLOYED AS AN AGENT BY A CORPORATION, please list the officers, directors, and any shareholders of the corporation having an interest of five percent (5%) or greater: American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Administrative and Judicial Proceedings 14a. Have you or anyone listed in your answer to Question 13 been convicted of a crime that, if committed in Indiana, would be a crime of moral turpitude or a felony: yes no 14b. If yes, please identify the crime, the court in which the case was tried and the sentence entered. Please attach the relevant documents (i.e. charges, conviction, sentence, etc.) from the court: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 15. Has there been any administrative or judicial determination that you or anyone listed in your answer to Question 13 has made a false, misleading, deceptive or fraudulent representation? If so, please identify the court or administrative agency that made such a determination and attach copies of the relevant documents: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 16. Please describe any instance in which your conduct or the conduct of any person named in your answer to Question 13 resulted in the imposition of a sanction, suspension, or declaration of ineligibility to participate in an interscholastic or intercollegiate athletic event on a student athlete or educational institution: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 17. Please describe any sanction, suspension or disciplinary action taken against the applicant or any person named in your answer to Question 13 arising out of occupational or professional conduct: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 18. Has there been a denial of an application for, suspension or revocation of, or refusal to renew the registration or licensure of yourself or any person named in your answer to Question 13 as an athlete agent in any state: If the answer is YES, please explain: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ I AFFIRM UNDER THE PENALITES FOR PERJURY THAT THE FOREGOING IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature: ______________________________________________ Printed Name: ______________________________________________ Date: ______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF NOTARY State of ____________________ SS: County of __________________ Before me the undersigned, a Notary Public for _________________________County, State of ________________, personally appeared ,and acknowledged the execution of this instrument this _______ day of ________________________, 200__ . SEAL (Signature)_______________________________ (Printed name)____________________________ My commission expires: ____________________________ To apply for your two-year registration as an athlete agent, please submit this completed form and a check or money order for seven hundred dollars ($700.00) made out to “Indiana Attorney General’s Office – Athlete Agent Registration” to: Office of Indiana Attorney General Greg Zoeller Consumer Protection Division Athlete Agent Registration Indiana Government Center South 5th Floor 302 West Washington Street Indianapolis, Indiana 46204 American LegalNet, Inc. www.FormsWorkFlow.com Athlete Agent Background Investigation Authorization Form (Please Read Carefully Before Signing) The Fair Credit Reporting Act (Amended 1997) requires that we inform you that a background investigation may be processed as part of our screening and selection process. This investigation may include inquiries to gather legal information regarding your personal characteristics, mode of living, character and general reputation. This information, if gathered, is used to verify specific information that you provided on your Application for Registration as an Athlete Agent. The items of personal information requested below are needed to process your background investigation. This information is intended solely for that purpose and will not be used in a discriminatory manner in the making of business decisions. Social Security # ________-_____-__________ Your Date of Birth _______________-_____-__________ (Month-Day-Year) Driver’s License # State of Issue List all your addresses for the past 7 years, starting with the most recent: (Must include present address) Street Zip From Address City State County Code Mo./Yr. To Mo./Yr. Have you ever been convicted of a crime (other than minor traffic offenses)? Yes______ No______ If Yes, please explain charges: (Use additional paper if necessary) What State, what County and What Year did these convictions occur? Other names you have used, including maiden name and the date(s) your name(s) changed: I authorize the Indiana Attorney General’s Office and their agents to investigate my background as it pertains to my Application for Registration as an Athlete Agent. This may include information contained in public records which could include credit history, criminal files at the county, state and federal jurisdiction levels, motor vehicle records and investigations of employment history and performance and educational credentials. I hereby release all persons, companies or corporations furnishing such information from liability and responsibility. A photo static copy of this document can be substituted for the original. This document shall be valid for a period of 1 (one) year from the date of my signature. Signature of Athlete Agent Applicant: Date:____/____/_____ Printed Full Name of Applicant 99846 American LegalNet, Inc. www.FormsWorkFlow.com