APPLYING/RENEWING AN ATHLETE AGENT LICENSE IN WEST VIRGINIA ACCORDING TO THE UNIFORM ATHLETE AGENTS ACT Chapter 30, Article 39 of the WV Code All athlete agents are required to register with the Secretary of State222s office prior to entering into a contract with a student-athlete or directly or indirectly recruiting or soliciting a student-athlete to enter into an agency contract. An athlete agent does NOT include a spouse, parent, sibling, grandparent, or guardian of the student-athlete or an individual acting solely on behalf of a professional sports team or organization. A certificate of registration as an athlete agent is valid for two (2) years. Fees: $50.00 original application $10.00 renewal application Complete all sections of the application. You may attach any additional information as required. SECTION I: APPLICANT INFORMATION SECTION II: BUSINESS INFORMATION Question #9 226 If your business is205 NOT a corporation = list must include partners, members, officers, managers, associates, or profit-sharers of the business A corporation = list must include officers, directors and any shareholders having an interest of 5% or more SECTION III: EDUCATION/TRAINING INFORMATION SECTION IV: ADMINISTRATIVE/COURT PROCEEDING INFORMATION When considering an application for an athlete agent, the following are considered: Has the applicant or any person named in SECTION II: Business Information of the application: 1.Been convicted of a crime that, if committed in this state, would be a crime involving moralturpitude or a felony; 2.Made a materially false, misleading, deceptive, or fraudulent representation in the applicationor as an athlete agent; 3.Engaged in conduct that would disqualify the applicant from serving in a fiduciary capacity;4.Engaged in conduct prohibited by section fourteen of this article;5.Had a registration or licensure as an athlete agent suspended, revoked, or denied or beenrefused renewal of registration or licensure as an athlete agent in any state; 6.Engaged in conduct, the consequence of which, was that a sanction, suspension, ordeclaration of ineligibility to participate in an interscholastic or intercollegiate athletic event was imposed on a student-athlete or educational institution; or 7.Engaged in conduct that significantly adversely reflects on the applicant222s credibility, honestyor integrity. In making a determination in regard to the above information, the Secretary of State shall consider: 1.How recently the conduct occurred;2.The nature of the conduct and the context in which it occurred; and3.Any other relevant conduct of the applicant.SECTION V: CLIENT INFORMATION SECTION VI: PERSONAL REFERENCES SECTION VII: OATH/AFFIRMATION *A civil penalty up to $25,000 may be assessed for a violation of the Uniform Athlete Agents Act.*Upon receipt in the Secretary of State222s office, all applicants for athlete agent are public information. Prohibited Conduct of an Athlete Agent (WV Code 30-39-14)An athlete agent, with the intent to induce a student-athlete to enter into an agency contract, may not: (the following actions are felonies) 1.Give any materially false or misleading information or make a materially false promise orrepresentation; 2.Furnish anything of value to a student-athlete before the student-athlete enters into the agencycontract; or 3.Furnish anything of value to any individual other than the student-athlete or anotherregistered athlete agent. An athlete agent may not intentionally: (the following actions are misdemeanors)1.Initiate a contract with a student-athlete unless registered under this article;2.Refuse or fail to retain or permit inspection of the records required to be retained by sectionthirteen of this article; 3.Fail to register when required by section four of this article;4.Provide materially false or misleading information in an application for registration orrenewal of registration; 5.Predate or postdate an agency contract; or6.Fail to notify a student-athlete before the student-athlete signs or otherwise authenticates anagency contract for a particular sport that the signing or authentication may make the student-athlete ineligible to participate as a student-athlete in that sport. Contract Information (Required WV Code 30-39-10) All agency contracts must contain the following in boldface type in capital letters. WARNING TO STUDENT-ATHLETE IF YOU SIGN THIS CONTRACT: 1.YOU MAY LOSE YOUR ELIGIBILITY TO COMPETE AS A STUDENT-ATHLETE INYOUR SPORT; 2.IF YOU HAVE AN ATHLETIC DIRECTOR, WITHIN 72 HOURS AFTER ENTERINGINTO THIS CONTRACT, BOTH YOU AND YOUR ATHLETE AGENT MUST NOTIFY YOUR ATHLETIC DIRECTOR; AND 3.YOU MAY CANCEL THIS CONTRACT WITHIN 14 DAYS AFTER SIGNING IT.CANCELLATION OF THIS CONTRACT MAY NOT REINSTATE YOUR ELIGIBILITY. If you have any questions, please contact205 West Virginia Secretary of State Attention: Licensing Division 1900 Kanawha Blvd., East Bldg. 1, Ste. 157-K Charleston, WV 25305 Phone: (304) 558-8000 Toll Free: 1-866-767-8683 Email: licensing@wvsos.gov Website: www.wvsos.gov SECTION I: APPLICANT INFORMATION1.Name of Applicant:2.Residence Address:3.Residence Phone:4.Birthdate:5.Social Security Number:SECTION II: BUSINESS INFORMATION6.Business Name:7.Business Address:8.Business Phone:9.Business Officers:If your business is not a corporation, please list the names & addresses of the partners, members, officers,managers, associates or profit-sharers of the business.If your business is a corporation, please list the officers, directors or any shareholders having an interest of 5%and greater.Name:Title/Company:Address:Name:Title/Company:Address:Name:Title/Company:Address:Name:Title/Company:Address:Name:Title/Company:Address:10.Business/occupation engaged in within previous five (5) years:SECTION III: EDUCATION/TRAINING INFORMATION11.Please list any formal training as an athlete agent:12.Please list any practical experience as an athlete agent:13.Please list educational background: West Virginia Secretary of State Business & Licensing Division Tel: (304)558-8000 Fax: (304)558-8381 Website: www.wvsos.gov Email: licensing@wvsos.gov APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT Form AAR-1 Rev. 11/2017$10.00 renewal application $50.00 original application Fees: SECTION IV: ADMINISTRATIVE/COURT PROCEEDING INFORMATION14.Have you ever been convicted of a crime involving moral turpitude or any felony in any stateduring the past ten (10) years?If yes, please provide details.15.Have you ever been sued by an athlete?If yes, please provide details.16.Have you ever filed bankruptcy?If yes, please provide details.17.Has any surety bond on which you were covered been required to pay any money on yourbehalf?If yes, please provide details.18.Have you ever been named in an administrative or judicial determination of false, misleadingor deceptive fraudulent representation?If yes, please provide details.19.Have you ever had a professional license, certificate or registration denied, suspended orrevoked by any other state?If yes, please provide details.20.Have you ever had any sanction, suspension or disciplinary action as a result of occupa-tional or professional conduct or conduct resulting in sanction, suspension or declaration ofineligibility of a student-athlete or educational institution?If yes, please provide de-tails. Page 2 SECTION V: CLIENT INFORMATION21.Please provide the name, sport and last known team for each individual for whom you haveacted as an athlete agent during the previous five years.Name:Sport:Team:Name:Sport:Team:Name:Sport:Team:Name:Sport:Team:Name:Sport:Team:SECTION VI: PERSONAL REFERENCES22.Please provide the names and addresses of three individuals who are not related to you asreferences.1)Name:Address:2)Name:Address:3)Name:Address:SECTION VII: OATH / AFFIRMATIONState of, County of.I,, do hereby certify under penalty of law, that the information containedherein is true, correct and complete to the best of my knowledge. I am aware that, should aninvestigation at any time disclose any such misrepresentation or falsification, my applicationcould be rejected or my certification revoked by the Secretary of State.Signature of ApplicantSubscribed and sworn before me on