COMMONWEALTH OF KENTUCKY APPLICATION FOR ATHLETE AGENT REGISTRATION -----Initial Application ($300.00) ------Renewal Application($100.00) ___Re-Instatement ($300.00) ____ Late Renewal Fee (60 Day Grace Period) ($150.00) _____Delinquent Renewal Fee ($200.00) 1. Name of Athlete Agent: ____________________________________________ 2. Social Security Number:____________________________________________ 3. Federal Employer Identification Number: __________________________ 4. Date of Birth: _______________________________________________________ 5. Business Address:________________________________ ________________________________ 6. Home Address:___________________________________ ___________________________________ (Please notify within 10 days any address changes) 7. Telephone Number: (____) ___________________________________ (Home) (___) _______________________________________ (Business) 8. Athlete Agent is a: _____ sole proprietor ____ corporation ____ partnership ___ limited liability company American LegalNet, Inc. www.FormsWorkflow.com 9. List the names and address of all persons that are financially interested as partners, associates, or profit sharers in the operation of the business of athlete agent. _________________________________________________ _________________________________________________ 10. Have you ever been convicted of any felony offense, misdemeanor or civil action involving moral turpitude in any state during the past ten (10) years?______________________ If yes, please describe circumstances. (yes/no) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 11.Have you ever been sued by an athlete? _____________If yes, please describe circumstances and disposition. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 12. Have you ever filed for bankruptcy? ______ If yes, please describe circumstances. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 13. Has any surety bond on which you were covered been required to pay any money on your behalf? ______ If yes, please describe. (yes/no) __________________________________________________________________________ __________________________________________________________________________ _________________________________________________________________________ 14. Are there any unsatisfied judgements of continuing effect against you? _____ If yes, provide full details. (yes/no) ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 15. List all professional sports in which you currently represent or have previously represented any professional athletes, and for each such sport, specify the name of the athlete(s) your currently represent. _________________________________________________________________________ _________________________________________________________________________ ________________________________________________________________________ 16. Do you manage, invest, or handle funds for athletes? ___________ (yes/no) If yes, are you bonded? ________________ If yes, please attach surety documentation. 17. Have you ever had a professional license, certificate or registration denied, suspended or revoked by any other state? ___________ If yes, please provide full details.___________________________________________ 18. What services does your firm provide to the athletes? (Place a check next to each service provided. Contract Negotiation ______ Grievance-Arbitration _____ Financial Planning ________ Other Services (Explain) _________________________ Estate Planning ________ Tax Planning ___________ Appearances/Endorsements _____ 19. If your firm does not provide services in one or more of the listed areas do you assist an athlete in securing such services? If so, describe what you do in this regard (include name and address of each individual you customarily refer athletes for each service)_________________________________________________________________ _________________________________________________________________________ ________________________________________________________________________ I, the applicant named in the above, do hereby certify under penalty of law, that the information contained herein is true, correct, and complete to the best of my knowledge and belief. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification, my application could be rejected or my certification revoked by the Division of Occupations and Professions. APPLICANT’S SIGNATURE____________________________DATE_______________________ American LegalNet, Inc. www.FormsWorkflow.com