Athlete-Agent Questionnaire The completion of this form does not satisfy the Wisconsin statue requiring athlete agents to file with the Department of Regulation and Licensing. Contact Information: State of Wisconsin Department of Regulation and Licensing 1400 East Washington Avenue, 1Room 173 PO Box 8935 Madison, WI 53708-8935 (608) 266-2112 http://drl.wi.gov web@drl.state.wi.us Statement of Understanding The following information is provided as a service to aid the University of Wisconsin-Madison’s Office of Athletic Compliance in better understanding the type and kinds of services and expertise offered by the respondent in preparation for future professional sports representation. It is acknowledged by all parties to this communication that the responses are intended to assist student-athletes in learning more about the particular firm and its agents/representatives. Part of this process is accomplished by reference to the information provided below – in other instances, by personal interview or meeting. Cognizant of the need to provide accurate and reliable information, it is understood by those reviewing this material that the answers provided can be relied upon for their veracity and accuracy. If additional information is required to respond to a specific question, please attach whatever documentation is appropriate. In submitting this form, I voluntarily agree to comply with and be bound by any applicable state law. I further understand that by making any false or misleading statement of any nature in answering a question on this form, that the firm or individual may be identified to all institutional representatives (including student-athletes, parents/legal guardians) and any other collegiate institution that may deem such lack of disclosure appropriate in counseling student-athletes regarding future professional sport opportunities. _____________________________________________________________________________________________ Agent’s Signature Date 1 American LegalNet, Inc. www.FormsWorkflow.com University of Wisconsin-Madison Athlete-Agent Questionnaire Section I: General Information Full Name: Have you ever been known by any other name or surname? ___Yes ___No Name of Your Organization: Your Title: Organization’s Address: City/State/Zip Code: Work Phone: Fax: Email: Section II: Agent I am a registered athlete agent, in good standing with the State of Wisconsin. Yes No I am a certified agent, in good standing as of the date of the completion of this form with the following: (check all which apply) Major League Baseball Players Association National Basketball Players Association National Football League Players Association National Hockey League Other, please list 2 American LegalNet, Inc. www.FormsWorkflow.com Section III: Education Law or Graduate School Attended: ________________________________________________________________________ (School) (City, State) ________________________________________________________________________ (Degree) (Date Awarded) ________________________________________________________________________ (School) (City, State) ________________________________________________________________________ (Degree) (Date Awarded) College or Universities Attended: ________________________________________________________________________ (School) (City, State) ________________________________________________________________________ (Degree) (Date Awarded) ________________________________________________________________________ (School) (City, State) ________________________________________________________________________ (Degree) (Date Awarded) High School Attended: ________________________________________________________________________ (School) (City, State) ________________________________________________________________________ (Degree) (Date Awarded) 3 American LegalNet, Inc. www.FormsWorkflow.com Section IV: Lawyers/Law Graduates (If you are not a lawyer or law graduate, please proceed to Section V) A. Please list the jurisdictions in which you have been admitted to the Bar and the corresponding dates of admission: Jurisdiction Date of Admission Status B. Do you have any application for Bar admission currently pending? If yes, please state where you have applied and the status of the application: C. If you have ever been disbarred, suspended, reprimanded, censured or otherwise disciplined or disqualified as an attorney, a member of any other profession, or a public office holder, please provide the following information: Action Date of Occurrence Authority Imposing Authority’s Address D. If any charges or complaints are currently pending against you regarding your conduct as an attorney, a member of any profession, or a public office holder, please provide the following information: Charge/Complaint Pending Authority Considering Authority’s Address E. Has your right to practice before any governmental office, bureau, agency, commission, etc., ever been disqualified, suspended, withdrawn, denied, or terminated? __________YES __________NO If Yes, please explain: 4 American LegalNet, Inc. www.FormsWorkflow.com Section V: Professional Background (All Applicants) A. List your employment history for the last (10) years. B. Please list below the names of all athletes and coaches you are now representing or have represented in the past (5) years in individual contract negotiations with professional sports teams indicating the dates of representation and the team(s) involved. If the total of your clients for this time period exceeds ten, list only your present and former clients in any sport in which you are seeking to represent a University of Wisconsin student-athlete primarily in the sports of football, basketball and ice hockey. If you prefer, you may attach a list with this information. Athlete’s Name & Address Dates Teams 5 American LegalNet, Inc. www.FormsWorkflow.com C. Please identify your areas of expertise in reference to professional sports/agent representation: D. List any occupational or professional licenses or other similar credentials you have obtained other than college or graduate degrees, including the dates they were obtained: E. If you have ever been denied an occupational or professional license, franchise or other similar credentials for which you applied, please explain: F. If you have ever been suspended, reprimanded, censured, or otherwise disciplined or disqualified as a member of any profession, or as a public office holder, please indicate below: Action Date of Occurrence Authority Imposing Authority’s Address 6 American LegalNet, Inc. www.FormsWorkflow.com G. Has your right to engage in any profession or occupation ever been disqualified, suspended, withdrawn or terminated? YES NO If YES, please explain: H. If you have ever been disciplined or cited for a violation of a state statute regulating athlete agents, please complete the following. Charge/Complaint Date of Alleged Violation Status Authority Imposing 7 American LegalNet, Inc. www.FormsWorkflow.com Section VI: Compliance Background NCAA If you have ever been involved or accused of participating in any action alleged to have been in violation of the rules of the NCAA, any conference, any university or college, any players association, and/or sports club, league, federation or team, please complete the below: Date of Alleged Violation Allegation Result/Status Authority Imposing Criminal Charges If you have ever been convicted of or pled guilty to a criminal charge, other than minor traffic violations, please complete the below: Date of Conviction Offense Criminal Authority Involved Punishment Assessed Other Compliance Issues Have you ever been a defendant in any civil proceedings, including bankruptcy, in which allegations of fraud misrepresentation, embezzlement, misappropriation of funds, conversion, breach of fiduciary duty, forgery, or legal malpractice were made against you? YES NO Has any court ever adjudicated you insane or legally incompetent? YES NO Have you ever been suspended or expelled from any college, university, law school or graduate school? YES NO Are there any unsatisfactory judgments of continuing effect against you? YES NO Have you been declared bankrupt or been an owner or part owner in a business which declared bankruptcy? YES NO IF YOU ANSWERED YES TO ANY OF THESE QUESTIONS, PLEASE ATTACH A WRITTEN EXPLANATION FOR EACH. 8 American LegalNet, Inc. www.FormsWorkflow.com Section VII: Services A. Please indicate the services you/your organization offer to athletes (check all that apply): Contract Negotiation Financial Planning Appearances/Endorsements Tax Planning Estate Planning Insurance Planning/Coverage Investment Counseling Grievance/Arbitration Other Services B. Please Indicate whether your organization does the following: 1. Do you offer separate contracts for each service? 2. Do you handle athletes’ funds? If yes, are you bonded? 3. Are you currently registered under the Investment Advisor’s Act? 4. Do you receive a fee from any individual(s)/firm(s) for referral? If yes, what is the basis of any fee? 5. If you assist players with securing the services you do not provide, please indicate below the individual(s)/firm(s) to which you customarily refer players for each service: Services Individual Firm Address Phone 6. How and when are you paid? 7. Who actually negotiates contracts on behalf of the athletes? 8. What is the duration of the agreement between you and the athlete? 9. What happens if you or the athlete wants to terminate the agreement? 10. What happens to the agreement if the athlete is waived from a team? 9 American LegalNet, Inc. www.FormsWorkflow.com Section VIII: References Please provide a list of three character references who are not related to you, not engaged in business with you, have known you for at least three years, and can attest to your character. For each, provide the following information: Name Address Phone Relationship Please provide a list of at least two entities which can attest to your financial credit. Organization Contact Address Phone 10 American LegalNet, Inc. www.FormsWorkflow.com Acknowledgement I certify that the information provided on this questionnaire is complete and correct. I have read the forgoing questions and have personally answered the same fully and honestly. The answers to said questions are true and accurate to the best of my knowledge. (Applicant’s Signature) (Date) Please return questionnaire to: Steve Waterfield Assistant Athletic Director for Compliance University of Wisconsin-Madison 1440 Monroe Street Madison, WI 53711 (608) 265-2973 scw@athletics.wisc.edu 11 American LegalNet, Inc. www.FormsWorkflow.com