OFFICE OF THE MISSISSIPPI SECRETARY OF STATE Post Office Box 136, Jackson, MS 39205-0136 (601)359-9055 Application for Registration or Renewal of Athlete Agent A Certificate of Registration or a renewal of a registration of an Athlete Agent is valid for two (2) years. Pursuant to Section 73-42-9 of the Miss. Code Ann. (1972), as amended, the undersigned hereby submits the following Application for Registration. New Application Renewal Phone Number: ________________________ A. Name and address of applicant: ______________________________________________ Name:_______________________________________________________________________ Address:_____________________________________________________________________ City: __________________________________________ State:______ Zip:______________ Email address: ________________________________________________________________ Website address:______________________________________________________________ B Name and address of the applicant's business or employer, if applicable: ____________________________________________________________________________ C. Please state the business or occupation engaged in by the applicant for the five (5) years preceding the date of submission of the application, including the name and address of such business (es): ____________________________________________________________________________ Athlete Agent F00 Revised 11/16 1 American LegalNet, Inc. www.FormsWorkFlow.com D. Please provide a description of the applicant's: (a) Formal training as an athlete agent: ____________________________________________________________________________ (b) Practical experience as an athlete agent: ____________________________________________________________________________ (c) Educational background relating to applicant's activities as an athlete agent. ____________________________________________________________________________ E. Please provide as references the names, addresses, and phone numbers of three (3) individuals not related to the applicant: Name: _______________________________________ Phone:________________________ Address:_____________________________________________________________________ City:___________________________________________State:_______Zip: ______________ Name: _______________________________________ Phone:________________________ Address: ____________________________________________________________________ City: __________________________________________State:________ Zip:______________ Name: _______________________________________ Phone: ________________________ Address: ____________________________________________________________________ City: __________________________________________State:________ Zip:______________ Athlete Agent F0091 Revised 11/16 2 American LegalNet, Inc. www.FormsWorkFlow.com F. Please provide the name, sport, and last known team for each individual for whom the applicant provided services as an athlete agent during the five (5) years preceding the date of submission of the application. Name and sport: ______________________________________________________________ Last known team: _____________________________________________________________ Name and sport: ______________________________________________________________ Last known team: _____________________________________________________________ Name and sport: ______________________________________________________________ Last known team: _____________________________________________________________ (If additional space is needed, please attach a list to this application.) G. (a) If the Athlete Agent's business is a corporation or LLC, please provide names and addresses for all officers, directors, and any shareholders or members of the corporation or LLC with a 5% or greater interest: Name: ______________________________________________________________________ Address:_____________________________________________________________________ City:___________________________________________State:______ Zip: ______________ Name: ______________________________________________________________________ Address: ____________________________________________________________________ City: __________________________________________State:________Zip:_____________ Name: ______________________________________________________________________ Address: ____________________________________________________________________ City: __________________________________________State:________Zip:_____________ (If additional space is needed, please attach a list to this application.) Athlete Agent F0091 Revised 11/16 3 American LegalNet, Inc. www.FormsWorkFlow.com G. (b) If the athlete agent's business is NOT a corporation or LLC, please produce names and addresses of all partners, individuals, associates, officers: Name: ______________________________________________________________________ Address:_____________________________________________________________________ City:___________________________________________State:_______Zip: _______________ Name: ______________________________________________________________________ Address: ____________________________________________________________________ City: __________________________________________State:________ Zip:_____________ Name: ______________________________________________________________________ Address: ____________________________________________________________________ City: __________________________________________State:________ Zip:______________ (If additional space is needed, please attach a list to this application.) H. Has the applicant or any other person named pursuant to paragraph G above ever been convicted of a crime that, if committed in this state, would be a felony or other crime involving moral turpitude? A crime (misdemeanor or felony) involving moral turpitude is one in which deceit is an element of the crime. Yes No If yes, please state the name of that individual and identify the crime. Name: ___________________________________________________________________ Identity of the crime: ________________________________________________________ Athlete Agent F0091 Revised 11/16 4 American LegalNet, Inc. www.FormsWorkFlow.com I. Has there ever been any administrative or judicial determination that applicant or any other person named in paragraph G made a false or misleading, deceptive, or fraudulent representation? Yes If yes, explain: No _______________________________