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Athlete Agent Amendment To Disclosure Statement SF-AA1 - California
| Athlete Agent Amendment To Disclosure Statement Form. This is a California form and can be used in Special Filings Secretary Of State . |
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State of California Secretary of State ATHLETE AGENT AMENDMENT TO DISCLOSURE STATEMENT A $20.00 filing fee must accompany this form. When completing form, please type or print in black ink. IMPORTANT-- Read instructions before completing this form. FILING OF FALSE, MISLEADING, OR INCOMPLETE STATEMENTS ON THIS FORM MAY SUBJECT YOU TO CRIMINAL AND CIVIL PENALTIES UNDER THE MILLER-AYALA ATHLETE AGENTS ACT, CHAPTER 2.5 (COMMENCING WITH SECTION 18895) OF DIVISION 8 OF THE BUSINESS AND PROFESSIONS CODE. 1. 2. 3. NAME OF ATHLETE AGENT FILE NUMBER WHICH IS AN INDIVIDUAL This Space For Filing Use Only OR ENTITY COMPLETE ONLY THE BOXES WHERE INFORMATION IS BEING CHANGED. ADDITIONAL PAGES MAY BE ATTACHED, IF NECESSARY. CONSULT THE INSTRUCTIONS BEFORE COMPLETING THIS FORM. A. NAME OF ATHLETE AGENT STATE STREET ADDRESS OF ALL LOCATIONS WHERE BUSINESS IS TO BE CONDUCTED, INCLUDING CITY, STATE, AND ZIP CODE (ATTACH ADDITIONAL PAGES IF NECESSARY.) A. B. C. C. NAME THE DESIGNATED AGENT FOR SERVICE OF PROCESS AND CHECK THE APPROPRIATE PROVISION BELOW: , WHICH IS [ ] AN INDIVIDUAL RESIDING IN CALIFORNIA. PROCEED TO ITEM D. B. [ ] A CORPORATION WHICH HAS FILED A CERTIFICATE PURSUANT TO SECTION 1505 OF THE CALIFORNIA CORPORATIONS CODE. PROCEED TO ITEM 6. D. IF AN INDIVIDUAL, STATE STREET ADDRESS OF THE AGENT FOR SERVICE OF PROCESS IN CALIFORNIA CITY STATE ZIP CODE CA E. LIST ALL BUSINESSES AND/OR OCCUPATIONS ENGAGED IN FOR THE TWO YEARS PRECEDING THE DATE OF THIS FILING (ATTACH ADDITIONAL PAGES IF NECESSARY) A. B. C. PLEASE CHECK YES OR NO TO QUESTIONS F THROUGH J. YES NO F. HAS THE ATHLETE AGENT EVER BEEN CONVICTED OF A FELONY? G. HAS THE ATHLETE AGENT EVER BEEN CONVICTED OF A MISDEMEANOR INVOLVING A VIOLATION OF CHAPTER 2.5 OF DIVISION 8 OF THE BUSINESS AND PROFESSIONS CODE, OR CHAPTER 1 (COMMENCING WITH SECTION 1500) OF PART 6 OF DIVISION 2 OF THE LABOR CODE AS REPEALED BY CHAPTER 857 OF THE STATUTES OF 1996, OR THE LAW OF ANY OTHER STATE GOVERNING ATHLETE AGENTS? H. HAS THE ATHLETE AGENT EVER BEEN CONVICTED OF FRAUD, THEFT, EMBEZZLEMENT, FRAUDULENT CONVERSION, OR MISAPPROPRIATION OF PROPERTY? I. HAS THE ATHLETE AGENT EVER MADE ANY APPEARANCES BEFORE ANY DISCIPLINARY OR PROFESSIONAL BOARD, ASSOCIATION, SECRETARY, COMMITTEE, OR OTHER ENTITY AS A RESULT OF DISCIPLINARY CHARGES OR OTHER ALLEGATIONS OF MISCONDUCT AGAINST THE ATHLETE AGENT? IF YES, EXPLAIN THE OUTCOME OF THOSE PROCEEDINGS. (ATTACH ADDITIONAL PAGES IF NECESSARY) HAS ANY STUDENT ATHLETE OR ANY EDUCATIONAL INSTITUTION BEEN SANCTIONED, SUSPENDED, OR DECLARED INELIGIBLE TO PARTICIPATE IN ONE OR MORE INTERSCHOLASTIC OR INTERCOLLEGIATE ATHLETIC EVENTS IN ANY PROCEEDING ARISING FROM, OR RELATED TO, THE ACTIONS OF THIS ATHLETE AGENT? NAME THE INSURER PROVIDING THE SECURITY REQUIRED BY SECTION 18897.87(a) AND STATE THE AMOUNT OF THE INSURANCE COVERAGE, IF PROVIDED CONSISTENT WITH THE REQUIREMENTS OF SECTION 18897.87(a) SPECIFY THE TYPE, VALUE AND SPECIFIC LOCATION OF SECURITY, IF PROVIDED CONSISTENT WITH THE REQUIREMENTS OF SECTION 18897.87(b) J. K. L. R. ATTACH A SCHEDULE OF FEES TO BE CHARGED AND COLLECTED IN THE CONDUCT OF THE ATHLETE AGENT BUSINESS. SECTION S THROUGH U APPLICABLE ONLY IF THE ATHLETE AGENT IS AN INDIVIDUAL S. T. 4. RESIDENCE ADDRESS OF ATHLETE AGENT SOCIAL SECURITY NUMBER OF ATHLETE AGENT I DECLARE THAT THIS DISCLOSURE STATEMENT IS TRUE, CORRECT AND COMPLETE. CITY U. STATE M. LIST ALL PAST AND PRESENT PERSONS ON BEHALF OF WHOM THE ATHLETE AGENT OR INDIVIDUAL HAS ACTED AS AN ATHLETE AGENT. (ATTACH ADDITIONAL PAGES IF NECESSARY) A. B. C. N. LIST THE NAMES OF ANY PLAYERS' ASSOCIATIONS WITH WHOM THE ATHLETE AGENT IS REGISTERED. (ATTACH ADDITIONAL PAGES IF NECESSARY) A. B. C. O. LIST AT LEAST THREE REFERENCES. (ATTACH ADDITIONAL PAGES IF NECESSARY) A. B. C. P. LIST ALL AFFIDAVITS OR CERTIFICATES OF COMPLETION OF ANY AND ALL FORMAL TRAINING OR PRACTICAL EXPERIENCE IN ANY OF THE FOLLOWING SPECIFIC AREAS: CONTRACTS, CONTRACT NEGOTIATION, COMPLAINT RESOLUTION, ARBITRATION, OR CIVIL RESOLUTION OF CONTRACT DISPUTES (ATTACH ADDITIONAL PAGES IF NECESSARY) A. B. C. Q. LIST THE NAMES AND RESIDENTIAL ADDRESSES OF ALL PERSONS FINANCIALLY INTERESTED IN THE OPERATION OF THE BUSINESS OF THE ATHLETE AGENT, WHETHER AS EMPLOYEES, PARTNERS, INVESTORS, ASSOCIATES, OR PROFIT SHARERS, OR IN ANY OTHER MANNER (ATTACH ADDITIONAL PAGES IF NECESSARY) A. B. C. ZIP CODE DRIVER'S LICENSE NUMBER OF ATHLETE AGENT SIGNATURE DATE TYPE OR PRINT NAME AND TITLE SEC/STATE (03/2005) FORM SF-AA1 FILING FEE: $20.00 Approved by Secretary of State American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS FOR COMPLETING THE ATHLETE AGENT AMENDMENT TO DISCLOSURE STATEMENT DO NOT ALTER THIS FORM Type or legibly print in black ink. · This form is to be used to amend information provided on initial Athlete Agent Disclosure Statements and/or any subsequent Athlete Agent Amendment to Disclosure Statements that have been filed. All amendments should include the name used on the initial Disclosure Statement filing to facilitate processing. Within seven days of the time any information in the filing required by Section 18896 changes, the athlete agent shall file revised information on an Amendment to Disclosure Statement. No revision of a fee schedule shall be effective until it is filed with the Secretary of State. Attach the twenty dollar ($20.00) fee for filing the Amendment to Disclosure Statement with the California Secretary of State. Attach any amended schedule of fees to be charged and collected in the conduct of this athlete agent business. Refer to Business and Professions Code Section 18895.2 for comprehensive definitions and exceptions to the definitions of athlete agent and person. Filing of false, misleading, or incomplete statements on this form may subject you to criminal and civil penalties under the Miller-Ayala Athlete Agents Act, Chapter 2.5 (commencing with Section 18895) of Division 8 of the Business and Professions Code. Send the executed document and filing fee to: California Secretary of State Special Filings Unit P.O. Box 942877 Sacramento, CA 94277-0001 · Fill in the items as follows: Enter the name of the athlete agent as filed with the California Secretary of State. Enter the file number issued by the California Secretary of State. Enter only the information in the Athlete Agent Disclosure Statement which is being amended by filing this Amendment to Disclosure Statement. Provide the text of each amendment adopted, using the space provided and/or att
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