West Virginia > Statewide > Athletic Agent Registration
Application For Registration As An Athlete Agent AAR-1w - West Virginia
| Application For Registration As An Athlete Agent Form. This is a West Virginia form and can be used in Athletic Agent Registration Statewide . |
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State of West VIrginia Betty Ireland, Secretary of State Building 1, Suite 157-K 1900 Kanawha Blvd., East Charleston, WV 25305 phone: 304/558-6000 email: wvsos@wvsos.com APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT SECTION I: APPLICANT INFORMATION 1. Name of Applicant: 2. Residence Address: 3. Residence Phone: 4. Birthdate: SECTION II: BUSINESS INFORMATION 6. 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. a. Name: Address: Title: b. Name: Address: Title: c. Name: Address: Title: d. Name: Address: Title: e. Name: Address: Title: 10. Business/occupation engaged in within previous five (5) years: 5. Social Security Number: SECTION III: EDUCATION/TRAINING INFORMATION 11. Please list any formal training as an athlete agent: 12. Please list any practical experience as an athlete agent: 13. Please list educational background: Page 1 Form AAR-1w Issued by the West Virginia Secretary of State 1/05 American LegalNet, Inc. www.FormsWorkflow.com SECTION IV: ADMINISTRATIVE/COURT PROCEEDING INFORMATION 14. Yes No Have you ever been convicted of a crime involving moral turpitude or any felony in any state during the past ten (10) years? If yes, please provide details. 15. Yes No Have you ever been sued by an athlete? If yes, please provide details. 16. Yes No Have you ever filed bankruptcy? If yes, please provide details. 17. Yes No Has any surety bond on which you were covered been required to pay any money on your behalf? If yes, please provide details. 18. Yes No Have you ever been named in an administrative or judicial determination of false, misleading or deceptive fraudulent representation? If yes, provide details. 19. Yes No Have you ever had a professional license, certificate or registration denied, suspended or revoked by any other state? If yes, please provide details. 20. Yes No Have you ever had any sanction, suspension or disciplinary action as a result of occupational or professional conduct or conduct resulting in sanction, suspension or declaration of ineligibility of a student-athlete or educational institution? If yes, please provide details. Form AAR-1w Issued by the West Virginia Secretary of State page 2 1/05 American LegalNet, Inc. www.FormsWorkflow.com SECTION V: CLIENT INFORMATION 21. Provide the name, sport and last known team for each individual for whom you have acted as an athlete agent during the previous five years. a. Name: Sport: Team: Name: Sport: Team: Name: Sport: Team: d. Name: Sport: Team: Name: Sport: Team: Name: Sport: Team: b. e. c. f. SECTION VI: PERSONAL REFERENCES 22. Provide the names and addresses of three individuals who are not related to you as references. 1) Name & Address: 2) Name & Address: 3) Name & Address: SECTION VII: OATH / AFFIRMATION State of , County of . I, , do hereby certify under penalty of law, that the information contained herein is true, correct and complete to the best of my knowledge. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification, my application could be rejected or my certification revoked by the Secretary of State. Signature of Applicant Subscribed and sworn before me on this My commission expires on day of . Signature of Notary Public , . (notary seal) Form AAR-1w Issued by the West Virginia Secretary of State page 3 1/05 American LegalNet, Inc. www.FormsWorkflow.com
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