UNIVERSITY OF MICHIGAN DEPARTMENT OF ATHLETICS 2010-11 University of Michigan Agent Questionnaire Note: This Form Must Be Completed In Its Entirety (please print or type) 1. General Information Name: ______________________________________ Date: _______________________________ Firm: ______________________________________ Daytime Phone: ______________________________ Address: ____________________________________ Evening Phone: ______________________________ ____________________________________ ______________________________ ____________________________________ 2. Fax: E-mail: ______________________________ Please list your educational background. Include dates attended and degrees conferred. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 3. Please list your employment history for the last ten (10) years. Attach additional sheets if necessary. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 4. Occupational or Professional Licenses Are you currently certified by the NFLPA? Yes ____ No ____ Permanent Provisional (circle one) Are you currently certified by the NBAPA? Yes ____ No ____ Permanent Provisional (circle one) Are you currently certified by the MLBPA? Yes ____ No ____ Permanent Provisional (circle one) Are you currently certified by the NHLPA? Yes ____ No ____ Permanent Provisional (circle one) Please list any other occupational or professional licenses or other similar credentials you have obtained other than college or graduate school degrees, including the dates they were obtained. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 5. How many years experience do you have representing client-athletes? _____________________________________________________________________________________ 6. Please identify which of the following services you provide for client-athletes: Contract Negotiation ____ Financial Planning ____ Hourly fee or percentage ____ Grievance Arbitration ____ Appearance/Endorsements ____ Legal Assistance ____ ____ Tax Planning ____ Hourly fee or percentage Estate Planning ____ Other services (please explain): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 7. Do you offer a separate contract for each of the services identified above? (please explain) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. Are your customary fees for the above services based on a percentage of the client’s salary that you negotiate, total income of the client, an hourly fee, or some other arrangement? (please explain) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 9. For the services you perform for client-athletes, list the names and addresses of individuals, firms, or agencies which assist in providing these services. Use additional sheets if necessary. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 10. Describe your fee structure. Are your fees negotiable? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 11. Do you expect to be paid for your services “up front” or as the player is compensated? _____________________________________________________________________________________ 12. Under what conditions may a client terminate a contract? _____________________________________________________________________________________ _____________________________________________________________________________________ 13. What happens if your client is waived from a team? _____________________________________________________________________________________ _____________________________________________________________________________________ 14. Do you limit the number of clients you will represent? If yes, please explain. ____________________________________________________________________________________ ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 15. Do you have an agreement, understanding, or relationship of any kind with any individual, firm, or organization pursuant to which such an individual, firm, or organization solicits or encourages clients to use your services? If yes, please explain, including whether or not you provide any compensation or other consideration to such an individual, firm, or organization. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 16. How many clients have you represented during your employment as a player agent? _____________________________________________________________________________________ 17. How many clients are you currently representing in your capacity as a player agent? ____________________________________________________________________________________ 18. Please provide the names and telephone numbers of five athletes that you previously or currently represent that may be contacted by the University of Michigan Compliance Services Office or a University of Michigan student-athlete. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 19. Please list all University of Michigan student-athletes that you currently represent or previously represented. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 20. Please list which current University of Michigan student-athlete(s) you plan to contact. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 21. Have you ever been disbarred, suspended, reprimanded, censured, or otherwise disciplined or disqualified as an attorney, as a member of any other profession, or as a holder or any public office? If yes, please describe each action, the dates of the occurrence, and the names and addresses of the authority imposing the action in question. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I certify that the above information is true, accurate, and complete to the best of my knowledge. Further, I certify that I will notify the Director of Athletics (or his designated representative) before the first contact with a studentathlete who had eligibility remaining in any sport and is enrolled at the University of Michigan. I also have reviewed the NCAA rules and regulations that accompany this form and have not engaged in any activity that would jeopardize the eligibility of any University of Michigan student-athlete. I understand that failure to comply with the terms of this certification and the applicable NCAA legislation may result in the initiation of legal proceedings by the University of Michigan against me and the assessment of civil and/or criminal penalties to me. Signature: _____________________________________ Date: ____________________________ Please return completed form and a photograph of yourself to: Elizabeth Heinrich Agent Liaison University of Michigan 1000 S. State Street Ann Arbor, MI 48109 Office: (734) 647-1194 Fax: (734) 763-7342 American LegalNet, Inc. www.FormsWorkFlow.com