Connecticut > Statewide > Department Of Consumer Protection > Athletic Licenses
University Of Connecticut Athlete Agent Registration - Connecticut
| University Of Connecticut Athlete Agent Registration Form. This is a Connecticut form and can be used in Athletic Licenses Department Of Consumer Protection Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
UCONN COMPLIANCE Ø ooz FORM UNIVERSITY OF CONI{ECTICUT REGISTRATION AS A}[ AGENT FOR STUDENT.ATHLETES AT THE UNWERSITY O['CONIìIECTICUT (Full Name) (Social SecwitY Number) (Business Name & Street Address) (Telephone Number) (Fax Number) (City, State, Zip) the purpose of potentially hereby register with the university of connecticut as an agent for 1 representing University of Connecticut student-athletes' I ask that my answers be considered as part of to this questionnaire, and my ansrwers to the questions found in any with a player's association, and all of my applications for certification as a contract advisor filed this registration. I recognize that making false or misleading statements in this registration may lead to a revocation of my registration. this registration also agree that all statements, agreements, and representations made in I are made for the benefit of the University of Connecticut and its student-athletes both presørt student-athletes who of Connecticut to and future, and that the information herein may be provided by the University its student-atbletes, as well as to other colleges/universities and their request it. I further agree to list ten (10) clients I have represented over the past three (3) years' please piace an + next to those narnes that you authorize the'University of Connecticut (and other colleges/universities and their student-athletes) to contact in regard to your character, your ten, performance, your services, etc. (If the total number of your clients for this period exceeds only your present and former clients in the sport in which you are seeking to you need list the sports represent a University of Connecticut student-athlete and such additional clients in football, basketball, baseball, oï soccer as are necssary for your list to contain ten naures.) of Si gnature o f Re gistrant American LegalNet, Inc. www.FormsWorkflow.com UCONN COMPLIANCE Ø oo¡ DATES OF REPRESENTATION t. 2. 3. 4. 5. 6. 7. 8. 9. 10. PLEASEPLACEANT6*',BEFoREA}TYATI{LETE,SNAMETIIATMAYBECoNTACTED. American LegalNet, Inc. www.FormsWorkflow.com @oot QuE srro NNATRE roR IE-glsrRATroN uNwERsIrY oF öÑùðiidui AS AN AGENT FOR srrmrNr-ATHLETES 1. General 4,. Full name of registrant: Ifyouareassociateclwithacompany'pleaselist: b. lotu*t and address) Haveyoueverbeenlcrownbyanyothernameorsurname(includingamaiden name)? (Yes orNo) If when used: yes, state all naÍIes used and d. 2. Date of Birth e. BirthPlace Education &, attended: Law or other graduate school (SchooÐ (City & State) To: Date of Attendance: From: Month/Yr' Month/Yr' Date Awarded: Degree: b. Colleges or Universities attended: (Name) (City & State) (City & State) 1Dut"s Attended) (Degree) (Dates Attended) (Degree) (Deg¡ee) (Narne) (Name) (cttv g state) þates Attended) American LegalNet, Inc. www.FormsWorkflow.com @ oos Higþ School Attended: (City & Søte) lD-rte-U.gr"eReceived) (Name) athlete agent? How long have you been an 4. All Registrants ^. If Bar in any State? Have you been admitted to the (Yes orNo) you afe admitted (also list any federal please indicate the state or states in which ves. in which vou are admitted)' i"å.ãiä,i.ts b. pending? Bar admission currently Do you have any applications for (Yes or No) If and the status of the application: yes, please state where you have applied l..Listanyotherprofessionalcertifications(suchasCPA,CFP,etc.)or professional licenses: 2'Listlicensingorcertifyingauthoritiesanddateslicensedorcertified: American LegalNet, Inc. www.FormsWorkflow.com Ø ooe 5. Al1. Registrants r' ìiLrùP!Àruvu' Have you ever been cllsoaÜe Haveyoueverbeendì1ba¡red'*:l¡*:1':'l'*ff;.1itrJ:îfåfi profession, or of any other as an attomey' a* ãä"aU"t ãiscipiined or disqualified office? ã* u ttot¿tt of anY Public (Yes or No) åi"'iii: Ifyes,pleased'escribeeachsuchaction'thedatesofoccunence'and'thenameand in question: th" ;;iltttvì*p"ti"g the action address "f b. against you regarding your any charges or complaints cunentlypending Are of public orunv ptor?'J*' oi as a holder as an attorn'ï, ã"ã*"*uo )' conduct nature of the offrce? charge or complaint äitit' pr:*e .,ru #"n;;. ;;ä ;åit.J-ïrtnr ôct-:äî;;^ indicate.the authoritv considering it: profession or occupation or to engage in any other Has your right to practice law withdraw' denied' or ever been disqualifieà, suspended' terminated? (Yes or No) ifn"ïr-r"*;æi"* n'tln d. Haveyoueverbeenconvictedorpledgurltytoacriminalcharge,otherthatminor -""]'* "^ ", yes-' please indicate 1Íes or No) If violations? traffic iinvolved, and punishment criminut authority nature of offense, ¿atãor "onui"tion, assessed: American LegalNet, Inc. www.FormsWorkflow.com UCONN COilPLIANCE Ø ooz 6. References you for a.Pleaselistbelowthenatnes,addresses,andtelephonenumbersofthreepersons'. i" úusirys.slviifr you, who have known not related to you and not fi"*U can attest to your character' at least the last three years uti¿irto b.Pleaselistbelowthenames,addressesnandtelephonenumbersofatleasttwo credit: entities which can attest to your financial 7. Other Qualifications a.AreyouregisteredwiththestateofConnecticutDepartmentofConsumer (Yes orNo) Protectioni- b. c. d. 8. A¡e you currently certified by the NFLPA? P errnanent or Provisional? Are you currently certified by the NBAPA? Are you currently certified by tle MLBPA? card) iuiát, pr""se enclose u "opy of your certification (Yes or No) (Yes or No) (Yes or No) Professional Services a. Do You handle PlaYers' funds? (Yes or No) Ifso, are Yòubonded? (Yes or No) Ifyes,pleaseprovidedetailsastotheamountofthebond,thenameandaddress of the surety or bonding company, etc': b, pa'rnent in advance, oï are y"* p;;;";;iét"i".O ervices' do You receive as the player is compensated? American LegalNet, Inc. www.FormsWorkflow.com . UCONN COMPLIANCE Ø ooe c. Are you a (S'E'C')? REGISTERED INVESTMENT ADVISOR Date Registered (Yes or No) d. addition to contract please indicate what services you offer to athletes, in negotiation services fee or percentage Playing contract negotiations- Hourly Endorsement contract negotiations -- Hourly fee or percentãge Financial planning Legalassistance Money Management Other Tax consultin g - - e.Doyouearnincomefromworkperformedinsomeoapacityotherthanasa or No) student-athleteiagent? (Yes Ifyes,describeotheroccttpation(s)orservice(s)forwhichyouarepaid: Whatapproximatepercentageofyourtotalworktimeisconsumedasastudentathleteiagent? f,Previousemploymetrt(lasttwopositionsanddatesofemployment) Fírm Address Position date
|
|||||||
