Arizona > Statewide > Athletic Agent Registration
Athlete Agent Application - Arizona
| Athlete Agent Application Form. This is a Arizona form and can be used in Athletic Agent Registration Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
ARIZONA STATE UNIVERSITY ATHLETE AGENT APPLICATION GENERAL INFORMATION Name Home Address Street Address City Home Phone Email Address If you are affiliated with a Law Firm/Agency/Company, please indicate below: Name of Firm/Agency/Co. Business Address Street Address State Cell Phone Zip Code Date of Birth City Business Phone State Zip Code EDUCATIONAL BACKGROUND Undergraduate Institution School Name Type of Degree Graduate/Legal Institution School Name Type of Degree Admitted to Bar Association (Circle One) YES NO State Date City Graduation Year State City Graduation Year State Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ARIZONA STATE UNIVERSITY ATHLETE AGENT APPLICATION QUALIFICATIONS Number of Years as a Agent/Advisor Current membership in professional organizations Occupational or professional license(s), and date(s) obtained Are you currently certified by any of the following Associations? NFLPA NBAPA MLBPA (circle one) (circle one) (circle one) YES YES YES NO NO NO (circle one) (circle one) (circle one) Permanent Permanent Permanent Provisional Provisional Provisional NO Are you currently registered as an athlete agent in the state of AZ? (circle one) YES *If you answered yes, please attach the certified copy of the completed registration from the Arizona Secretary of State's office.* Date of Certification in the State of AZ Have you ever been disciplined by any regulatory organization? If you answered yes, please describe: (circle one) YES NO Have you ever been convicted of a crime? If you answered yes, please describe: (circle one) YES NO Please list any athletes that you previously have, or currently are representing. Also, in team sports please include the team/league to which the athlete is under contract as well as the name of the team/league representative with whom the contract was negotiated. Please write the word "none" below if you have not represented any athletes and are not currently representing any athletes. Use additional sheets if necessary. Player Name Team/League Client Phone Team Rep. Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ARIZONA STATE UNIVERSITY ATHLETE AGENT APPLICATION ASU STUDENT-ATHLETES Please list the current ASU Student-Athletes that you are interested in representing: Student-Athlete Name Sport PREVIOUS EMPLOYMENT Please list your last two positions and dates of employment: Employer Dates of Employment Employer's Address Street City State Zip Code Position Employer Dates of Employment Employer's Address Street City Position State Zip Code Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ARIZONA STATE UNIVERSITY ATHLETE AGENT APPLICATION REFERENCES Reference Name Employer/Occupation Address Street Phone Number City State Zip Code Relationship Reference Name Employer/Occupation Address Street Phone Number Relationship City State Zip Code By signing below, I certify that the above information is true, correct, and complete to the best of my knowledge. Further knowledge Further, I certify that I will notify the Vice President of University Athletes (or her designated representative) before the first contact with a student-athlete who has eligibility remaining in any sport and is enrolled at Arizona State University or before the first contact with the student-athlete's coach. I also certify that I have reviewed the UAAA, NCAA and Arizona State University regulations and policies that accompany this form and will not/have not engaged in any activity prior to a student-athlete's agreement to be represented that would otherwise jeopardize the student-athlete's eligibility. I also understand that failure to comply with the terms of this certification and the applicable NCAA legislation may result in the initiation of legal proceedings by Arizona State University against me and the assessment of civil and/or criminal penalties to me. Signed Date Please return this completed form to Kristen Beasley at: Agent & Advisor Program / Compliance Services Arizona State University P.O. Box 872505 Tempe, AZ 85287 Phone: (480) 965-0116 Fax: (480) 965-0177 For Compliance use only: Date received: Date entered/conf.: AZSOS Date: Initials: Initials: Initials: Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
