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University Of Wisconsin Athlete Agent Questionnaire - Wisconsin
| University Of Wisconsin Athlete Agent Questionnaire Form. This is a Wisconsin form and can be used in Athletic Agent Registration Statewide . |
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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 If Yes, please explain: __________NO 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, pl
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