Wisconsin Department of Safety and Professional Services Mail To: P.O. Box 8935 FAX #: Phone #: 1400 E. Washington Avenue Madison, WI 53703 E-Mail: web@dsps.wi.gov Website: http://dsps.wi.gov Madison, WI 53708-8935 (608) 261-7083 (608) 266-2112 DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING RENEWAL APPLICATION FOR ATHLETE AGENT REGISTRATION Under Wisconsin law, the Department must deny your application if you are liable for delinquent state taxes or child support (sec. 440.12, Stats.). PLEASE TYPE OR PRINT IN INK Your name and address are available to the public. Check box to withhold street address/PO Box number from lists of 10 or more credential holders (Wis. Stat. § 440.14) Last Name First Name MI Former / Maiden Name(s) Your Street Address (number, street, city, state, zip) Mail To Address (if different) Date of Birth Daytime Telephone Number ___________ ___________ ____________ month day year Ethnic/gender status information is optional. Sex: M F ( Ethnic: ) ____________ - ________________________ White, not of Hispanic origin Black, not of Hispanic origin Hispanic Have you ever held a license/credential in the state of Wisconsin? If yes, provide your Wisconsin license/credential number. American Indian or Alaskan Asian or Pacific Islander Other _____Yes _____No (please indicate) ________________ The athletic agent license expires on July 1 of the even-numbered year. It may be renewed for a two year period at that time. QUALIFICATION: Mark an X in ONE space indicating how you qualify: Renewal Application for Athlete Agent Registration (Form #2733) Reciprocal/licensed in another state - Renewal application and certificate of registration attached. Application Fees: Please make check payable to the Department of Safety and Professional Services and attach to application. For Receipting Use Only $107 Renewal fee #2733 (Rev. 9/11) Ch. 440, Stats. Page 1 of 6 committed to Equal Opportunity in Employment and Licensing American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services STATEMENT OF ARREST OR CONVICTION: MARK AN X IN THE APPROPRIATE BOX If you answer YES to any question, give all details on a separate sheet. YES A. B. Has there been any denial of an application for, suspension or revocation of, or refusal to renew, the registration or licensure of the application for you or any of the persons listed on page 5 as an athlete agent. C. Has any licensing or credentialing agency ever taken any disciplinary action against you or any of the persons listed on page 5 including but not limited to any warning, reprimand, sanction, suspension, probation, limitation or revocation? If YES attach a sheet providing details about the action, including the name of the credentialing agency and date of action. D. Is disciplinary action pending against you or any of the persons listed on page 5 in any jurisdiction? If YES, attach a sheet providing details about the action, including the name of the agency and status of action. E. Have you or any of the persons listed on page 5 ever engaged in conduct that resulted in the imposition of a sanction, suspension or declaration of ineligibility to participate in an interscholastic or intercollegiate athletic event on a student athlete or educational institution? If YES, attach a sheet providing explanation signed and dated by the applicant including specific dates and submit copies of all letters of inquiry and resolution. F. Have you or any of the persons listed on page 5 ever been the subject of any administrative or judicial determination that the person has made a false, misleading, deceptive or fraudulent representation. If YES, attach a sheet signed and dated by the applicant explaining the circumstances of each incident, a copy of the complaint that states the charges and allegations and a copy of the final judgment that establishes resolution of the charges. G. NO Have you or any of the persons listed on page 5 ever been convicted of a misdemeanor or a felony, or driving while intoxicated (DWI) in this or any other state, OR are criminal charges or DWI charges pending against you? If YES, complete and attach Form #2252 with all required documentation. Do you currently hold, or have you or any of the persons listed on page 5 in the past held any credential (license) issued by the Department of Safety and Professional Services or any of the Boards? If YES, what type of credential? _____________________ And if another name, what name? _________________________ CERTIFICATION OF LEGAL STATUS I declare under penalty of law that I am (check one): _____ a citizen or national of the United States, or _____ a qualified alien or nonimmigrant lawfully present in the United States who is eligible to receive this professional license or credential as defined in the Personal Responsibility and Work Opportunities Reconciliation Act of 1996, as codified in 8 U.S.C. §1601 et. seq. (PRWORA). For questions concerning PRWORA status, please contact the U.S. Citizenship and Immigration Services in the Department of Homeland Security at 1-800-375-5283 or online at http://www.uscis.gov. ALL APPLICANTS MUST COMPLETE THIS SECTION AFFIDAVIT OF APPLICANT I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every respect. I understand that failure to provide requested information, making any materially false statement and/or giving any materially false information in connection with my application for a credential or for renewal or reinstatement of a credential may result in credential application processing delays; denial, revocation, suspension or limitation of my credential; or any combination thereof; or such other penalties as may be provided by law. I further understand that if I am issued a credential, or renewal or reinstatement thereof, failure to comply with the statutes and/or administrative code provisions of the licensing authority will be cause for disciplinary action. __________________________________________________________ Signature of Applicant ________________________________ Date Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services APPLICANT’S BUSINESS OR EMPLOYER (If you work alone, list your own name and address.) Name of Principal Place of Business Address of Principal Place of Business City State I am an employee. Title: Zip Code Business Telephone Number __________________________________________________________ Business Structure - check one and submit the disclosure of company owners, partners, officers on page 4 Individual Proprietor Corporation Partnership Other (Specify ______________________________________) NOTE: The Wisconsin Department of Safety and Professional Services only licenses individuals for this profession. Each person acting as an athlete agent in Wisconsin must be licensed in this state. Listing the business entry in this section and then providing the officers, partners and/or members on page 4 does not license the business nor does it entitle any of the individuals listed on page 4 to act as an athlete agent. Only the person applying for licensure can act as an athlete agent in Wisconsin when licensed. Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services DISCLOSURE OF COMPANY OWNERS, PARTNERS, OFFICERS NAME OF COMPANY: _____________________________________________________________________________________ An applicant for a license must provide the following information: • • • Individual Proprietor: Provide the name and address of the Owner. Partnership: Provide the name and address of all General Partners and Limited Partners. Corporation, LLC, Trust, Other: Provide the name and address of all elected Officers, Directors, Governors, Members, Shareholders owning 5% or more of company stock, and any Managers/Associates/Employees with authority to exercise control in policy or management of the company. If any owner or partner is also business entity, you must complete this form to disclose the owners/partners/officers/shareholders of that business entity as well. Name Address Title (check one) 100% Owner Elected Officer (title:______________________________) Shareholder (Percentage of Ownership: _______________) City, State, Zip General Partner Limited Partner Director LLC Governor/Member Manager/Associate/Employee with controlling authority Name Address Title (check one) 100% Owner Elected Officer (title:______________________________) Shareholder (Percentage of Ownership: _______________) City, State, Zip General Partner Limited Partner Director LLC Governor/Member Manager/Associate/Employee with controlling authority Name Address Title (check one) 100% Owner Elected Officer (title:______________________________) Shareholder (Percentage of Ownership: _______________) City, State, Zip General Partner Limited Partner Director LLC Governor/Member Manager/Associate/Employee with controlling authority Name Address Title (check one) 100% Owner Elected Officer (title:______________________________) Shareholder (Percentage of Ownership: _______________) City, State, Zip General Partner Limited Partner Director LLC Governor/Member Manager/Associate/Employee with controlling authority _____________________________________________________________ Signature of Applicant __________________________________________ Date Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services EMPLOYMENT HISTORY Provide employment history for the five (5) years preceding the date of this application. (Attach additional pages if necessary.) Employer Position Title Address City Dates of Employment From ____________ / ____________ / ____________ DESCRIPTION OF DUTIES To State Zip ____________ / ____________ / ____________ Employer Position Title Address City Dates of Employment From ____________ / ____________ / ____________ DESCRIPTION OF DUTIES To State Zip ____________ / ____________ / ____________ Employer Position Title Address City Dates of Employment From ____________ / ____________ / ____________ DESCRIPTION OF DUTIES To State Zip ____________ / ____________ / ____________ FORMAL TRAINING Does the applicant have formal training as an athlete agent? If yes, when was formal training obtained? Yes No From ___________ / ___________ / ___________ to ___________ / ___________ / ___________ Name of training facility: __________________________________________________________ Location: ___________________________________________ Provide a description of the formal training: PRACTICAL EXPERIENCE Does the applicant have practical experience as an athlete agent? If yes, when was practical experience obtained? Yes No From ___________ / ___________ / ___________ to ___________ / ___________ / ___________ At what business was practical experience obtained:_____________________________________ Location: ___________________________________________ Provide a description of the practical experience: EDUCATIONAL BACKGROUND Does the applicant have educational background related to activities as an athlete agent? If yes, when was educational background obtained? Yes No From ___________ / ___________ / ___________ to ___________ / ___________ / ___________ Name of educational facility: _______________________________________________________ Location: ___________________________________________ Provide a description of the educational background: Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Wisconsin Department of Safety and Professional Services CREDENTIALS Has the applicant acted as an athlete agent during the five (5) years prior to this application? Yes No If yes, provide the name, sport and last known team for each individual for whom you acted as an athlete agent during the 5 years prior to submitting this application. (Attach additional sheets if necessary.) Athlete Name Sport Last Known Team Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com