NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE P. O. Box 29622 Raleigh, NC 27626-0622 www.sosnc.com 919-733-3924 APPLICATION FOR RENEWAL REGISTRATION AS AN ATHELET AGENT §78C-90(d) APPLICATION MUST BE TYPED OR PRINTED. PLEASE NOTE THAT THIS APPLICATION MAY BE SUBMITTED ONLY IN THE NAME OF THE INDIVIDUAL SEEKING REGISTRATION AS AN ATHLETE AGENT. "INDIVIDUAL" REFERS TO A SINGLE HUMAN BEING.* THIS APPLICATION MUST CONTAIN CURRENT INFORMATION ON ALL MATTERS REQUIRED IN YOUR ORIGINAL REGISTRATION. Date: __________________________________ RENEWAL GENERAL INFORMATION 1. 2. Applicant's Name: _______________________________________________________________ Name of Applicant's Business or Employer (if applicable): _______________________________ _______________________________________________________________________________ 3. Address of Applicant's Principal Place of Business: Street Address __________________________________________________________________ Post Office Box _________________________________________________________________ City/State/Zip Code ______________________________________________________________ Telephone (_______)______________________________________________________ E-mail (optional) _____________________________________ __________________________ 4. Business/Occupation. Since the initial (or last) application filed, has there been any changes in the business or occupation engaged in by applicant? If yes, please provide the following information: Business Name___________________________________________________________________ Title ___________________________________________________________________________ Dates in Position _________________________________________________________________ Business Address_________________________________________________________________ Supervisor's Name _______________________________________________________________ Business Phone __________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 5. Since the initial (or last) application filed, are there any new individuals for whom the applicant has acted as an athlete agent? Yes ________ No _______. If yes, please provide the following information: Name Sport Last Known Team Dates of Representation ____________________________________________________ __________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 6. Business Membership A. Non-Corporations. If applicant listed his/her business as a non-corporation in the initial (or last) application filed, are there any change(s) of names and addresses of : 1) partners; 2) members; 3) officers; 4) managers; 5) associates; and 6) profit-sharers associated with the business or employer? If yes, please provide the following information: Name Address Name Address Name Address Name Address Name Address Position Position Position Position Position B. Incorporated Business Entities. If applicant listed his/her business as a corporation in the initial (or last) application filed, are there any changes of names/addresses of 1) officers; 2) directors; 3) any shareholders of the corporation having an interest of five percent (5%) or greater associated with the corporation? If yes, please provide the following information: Name Address Name Address Name Address Name Address Name Address Position Position Position Position Position American LegalNet, Inc. www.USCourtForms.com 7. Applicant and Business Membership Conduct Since the initial (or last) application filed, please state whether or not the applicant or any person affiliated with applicant's business has been convicted of a crime involving moral turpitude or a felony in: 1) criminal convictions; 2) making false, misleading, deceptive or fraudulent misrepresentations; 3) conduct negatively impacting upon either student athletes or educational institutions; 4) occupational or professional conduct; or 5) denial, suspension, revocation or refusal to renew registration or licensure as an athlete agent in any state? If yes, describe each instance. Include a separate entry for each person named in response to this section. (Attach additional sheet as needed.) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ OATH/AFFIRMATION I do hereby swear (affirm) that the information furnished in this form (and ____ attached pages, if any) is true and correct to the best of my knowledge under penalty of perjury. I understand that giving false information in this form constitutes cause for denial of my application or revocation of my Registration and could subject me to criminal prosecution. Signature of Applicant: _________________________________________________ Date: ____________________________________ State of _____________________________ County of ____________________________ Sworn and subscribed to me this ____ day of ___________________, ___________. Month Year __________________________________________ Notary Public Signature My Commission Expires: _______________________ Notary Seal American LegalNet, Inc. www.USCourtForms.com Make checks payable to: NC Department of the Secretary of State. FEES - $200.00 APPLICATION FEES ARE NONREFUNDABLE RENEWAL OF REGISTRATION AS AN ATHLETE AGENT Please check one. _____ NC APPLICATION FOR RENEWAL OF REGISTRATION _____ OTHER STATE APPLICATION FOR RENEWAL OF REGISTRATION NOTICE OF ALTERNAT