WVU Agent Registration Form

Appendix A Agent Registration Form 1) General Name: ___________________________ SS#: _____________________________ Date of Birth: ____________________________ Phone: (_____)___________________________ If affiliated with a particular firm or agency as a player-agent, please indicate: Name of Firm/Agency: ________________________________________________________ Business Address: ________________________________________________________ ______________________________________(____)_____________ City Cell Phone ___________________________ E-mail II) Education High School: Name: _______________________________________Year Graduated: _____ City State College: Name: __________________________________________________________ City State Degree(s) and Year Graduated: ______________________________________ Graduate/Legal: College/University: ________________________________________________ City State Degree(s) and Year Graduated: _______________________________________ Admitted to Bar (If Applicable) Yes____ No____ State________ Date________ State Zip Business Phone (____)_____________ Fax (____)_____________________ American LegalNet, Inc. www.FormsWorkFlow.com III) Experience Number of years experience as a player-agent: _______________________ Sports in which you currently represent athletes and total number of athletes in each sport: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ IV) Other Qualifications Current membership in professional organizations: ______________________________________________________________________________ ______________________________________________________________________________ Occupational or professional licenses and date obtained: ______________________________________________________________________________ ______________________________________________________________________________ Are you currently certified by the NFLPA? Are you currently certified by the NBPA? Are you currently certified by the MLBPA? Yes____ No____ Permanent Provisional (Circle One) Yes____ No____ Permanent Provisional (Circle One) Yes____ No____ Permanent Provisional (Circle One) V) Professional Services General Services performed for client-athletes (check those that apply and indicate fee charged): Playing contract negotiations: Yes____ No____ Endorsement contract negotiations: Yes____ No____ Legal Assistance__________ Financial Planning________ Hourly Fee or Percentage: __________ Hourly Fee or Percentage: __________ Tax Consulting__________ Money Management______ American LegalNet, Inc. www.FormsWorkFlow.com For those services you perform for client-athletes, list the names and addresses of individuals, firms, or agencies that assist you in providing these services. Use additional sheets if necessary: ______________________________________________________________________________ Name City State ______________________________________________________________________________ Name City State In receiving compensation for contract negotiations services, do you receive payment "up front" or are your payments received as the player is compensated? ______________________________________________________________________________ Please list the names of any athletes, including West Virginia University athletes, that you previously or currently represent and, in team sports, the team/league to which each athlete is currently under contract and the name of the team representative whit whom you negotiated this contract. Write "none" if you currently do not represent any athlete. If you represent athletes in more than one sport, please provide this information for at least five clients in each sport. Use additional sheets if necessary: Player Name Team Client's Phone Team Rep. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list the names of any West Virginia University student-athletes that you wish to contact: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you earn income from work performed in some capacity other than as a player agent? ______ If yes, please describe the other occupation or services for which you are paid: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com VI) Previous Employment Firm: ___________________________ Address: ________________________ Firm: ___________________________ Address: ________________________ VII) References (3) (1) Name: _______________________ Address: _____________________ (2) Name: _______________________ Address: _____________________ (3) Name: _______________________ Address: _____________________ Phone: (____)_____________________________ City/State: _______________________________ Phone: (____)_____________________________ City/State: _______________________________ Phone: (____)_____________________________ City/State: _______________________________ Position/Date: _____________________________ City/State: _______________________________ Position/Date: _____________________________ City/State: _______________________________ I certify that the above information is true, correct, and complete to the best of my knowledge. Further, I certify that I have reviewed the Agent Policy as outlined per WVU's Professional Football Education Program and will adhere to all parameters within the policy. Furthermore, I have reviewed NCAA rules and regulations and have not engaged in any activity prior to a student-athlete's agreement to be represented that would jeopardize the studentathlete'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 West Virg