STATE OF MINNESOTA DEPARTMENT OF COMMERCE 85 7 th PLACE EAST, SUITE 280 ST. PAUL, MINNESOTA 55101 (651) 539 - 159 9 (For Department Use Only) ATHLETE AGENT REGISTRATION APPLICATION REGISTRATION NUMBER DATE PROCESSED Ten nessen Warning Notice Important information that you should read before completing this form appears on page 10 . Please read the application carefully and complete all informati on requested. The applicant must be an individual , and the application must be signed by the applicant. Keep a copy of the application for your records. For further information on the application process, applicants may contact the Licensing Division at (651) 539 - 1599 or via e - mail, licensing.commerce@state.mn.us . GENERAL INFORMATION Full Legal Name (please print or type) Date (Month/Day/Year) and Place of Birth Residence Address City State Zip Code Social Security Number Residence Telephone Number ( ) Work Telephone Number ( ) Mobile Telephone Number ( ) Fax Number ( ) E - mail Address for Business Use Personal Web S ites Affiliated Social Media Accounts List any professional or occupational license, registratio n, or certification held by the applicant during the five years before the date of this application. 1 American LegalNet, Inc. www.FormsWorkFlow.com PRINCIPAL PLACE OF BUSINESS (If you work alone, list your own name and address.) Name of Principal Place of Business Ad dress City State Zip Code Mailing Address City State Zip Code Business Telephone Number ( ) Business Web Sites Nature of the Business Affiliated Social Media Accounts Business Organization Form (check one) Individu al Proprietor Corporation Partnership Association Limited Liability Company Limited Liability Partnership Other (Specify: ) 2 American LegalNet, Inc. www.FormsWorkFlow.com ER (if different from above) or ADDITIONAL EMPLOYER/PLACE OF BUSINESS This information must be provided for each business or employer. Attach additional page s as necessary. Name of Principal Place of Business Address City State Zip Code Mailing Address City State Zip Code Business Telephone Number ( ) Business Web Sites Nature of the Business Affiliated Social Media Accounts Business Organization Form (check one) Individual Proprietor Corporation Partnership Association Limited Liabili ty Company Limited Liability Partnership Other (Specify: ) 3 American LegalNet, Inc. www.FormsWorkFlow.com CREDENTIALS PRIOR CLIENTS Has the applicant acted as an at hlete agent during the five years prior to this application? Yes No If yes, provide the name, sport, and team for each student athlete for whom you acted as an athlete agent during the five ye ars prior to this application. A ttach additional pages if necessary . If the individual is a minor, provide the name of the p arent or guardian of the minor . NAME SPORT LAST KNOWN TEAM CURRENT REGISTRATIONS AND PENDING APPLICATIONS List each state in which the applicant currently is registered as an athlete agent or has applied to be registered as an athl ete agent. STATE STATUS STATE STATUS Registered Pending Registered Pending Registered Pending Registered Pending Registered Pending Registered Pending Registered Pending Registered Pending Registered Pending Registered Pending EMPLOYMENT HISTORY Provide employment history for the five (5) years preceding the date of this application. Include self - employment and employment by others . At tac h additional pages if necessary. Employer Position Title Address City State Zip Code Dates of Employment From // To // Description of Duties Employer Position Title Address City State Zip Code D ates of Employment From // To // Description of Duties 4 American LegalNet, Inc. www.FormsWorkFlow.com FORMAL TRAINING Does the applicant have formal training as an athlete agent? Yes No If yes, when was formal training obtained? From // to // Name of training fa cility Location Provide a descr iption of the formal training: PRACTICA L EXPERIENCE Does the applicant have practical experience as an athlete agent? Yes No If yes, when was the practical experience obtained? From // to // Name of business Location Provide a descr iption of the practical experience: EDUCATIONAL BACKGROUND Does the applicant have a n educational background relating to acti vities as an athlete agent? Yes No If yes, when was the education obtained? From // to // Name of educational fa cility Locat ion Provide a descr iption of the education: 5 American LegalNet, Inc. www.FormsWorkFlow.com PROFESSIONAL LEAGUES OR PLAYERS ASSOCIATIONS Is the applicant certified or registered by a professional league or players association? Yes No If yes , provide the following information for each league and associa tion . Attach additional pages if necessary. Organization name Date of certification or registration Date of expiration of the certification or registration Organization name Date of certification or registration Date of expiration of the certification or registration Organization name Date of certification or registration Date of expiration of the certification or registration Provide the following information, if applic able: the date of a denial of an application for, suspension or revocation of, refusal to renew, withdrawal of, or termination of, certification or registration by a professional league or players association, or any reprimand or censure related to certifi cation or registration by a professional league or players association. 6 American LegalNet, Inc. www.FormsWorkFlow.com If the business employing the athlete agent is NOT a corporation , list the name and address of each person that is a partner, member, officer, man ager, associate, or profit sharer or directly or indirectly Attach additional pages if necessary. RELATIONSHIP TO BUSINESS (check one) FULL NAME ADDRESS Partner Membe r Officer Manager Associate Profit sharer Equity interest If the business employing the athlete agent IS a corporation , list the name and address of each person that is an officer or director of the corporation or a shareholder having an i nterest of five percent or greater in the corporation. Attach additional pages if necessary. FULL NAME ADDRESS RELATIONSHIP TO BUSINESS (check one) Officer Director Shareholder with Officer Director Shareholder with Officer Director Shareholder with Offic er Director Shareholder with Officer Director Shareholder with Officer Director Shareholder with 7 American LegalNet, Inc. www.FormsWorkFlow.com The following questions must be reviewed and answered by the applicant and each of the individuals and provide the indicated documentation with the application. (a) Has the applicant or any person listed above applied for a state or federal business, professional, or occupational license, other than as an athlete agent, from a state or federal agency? If yes , provide the name of the license type and a description of the status of the application, including any denial, refusal to renew, suspension, withdrawal, or termination of the license and any reprimand or censure related to the license. Yes No (b) Has the applicant or any person listed above pleaded guilty or no contest to, or been convicted of, a crime that would involve moral turpitude or be a felony if committed in Minnesota, or does the applicant or any person listed abo ve have charges pending for a crime that would involve moral turpitude or be a felony if committed in Minnesota? If yes , identify the crime, the law enforcement agency involved, and if applicable, the date of the conviction and the fine or penalty imposed. Yes No (c) Within 15 years before the date of this application, has the applicant or any person listed above been a defendant or respondent in a civil proceeding, including a proceeding seeking an adjudication of legal inc ompetence? If yes , specify the date and fully explain each proceeding. Yes No (d) Does the applicant or any person listed above have an unsatisfied judgment or a judgment of continuing effect, including spousal maintenance or a domestic order in the nature of child support, that is not current at the date of this application? If yes, fully explain the unsatisfied judgment. Yes No (e) Within ten years before the date of this appli