Indiana University Agent Advisor Registration Application

INDIANA UNIVERSITY ATHLETICS Agent/Advisor Registration Application Office of Compliance Services AGENTS, FINANCIAL ADVISORS , & DISABILITY INSURANCE PROVIDERS: All agent/advisor registration applications must be filled out completely and contain the required forms listed in the C ertification Section (Section VIII ) of the application. Individuals who submit incomplete applications will be notified of the missing information and the application will not be processed until all required information has been received. If an application is complete, the individual will be notified by e - mail that the registration has been approved. Registration (Check All That Apply ) Athlet e Agent Financial Advisor/Planner Disability Insurance Provider I. Applicant General Information: Companies with multiple applicants should complete a form for each person applying. Applicant Name (Last, First, Middle): Date of Birth: Work Phone: Cell Phone: Fax: Applicant Email: Company Name & Website Address (if applicable) : Company Street Address: City: State: Zip Code: Educational Background (Please list year of graduation(s), all degrees and the awarding educational institutions): II: Names of IU Student-Athletes: Please list the names of the IU Student-Athletes you intend to contact. American LegalNet, Inc. www.FormsWorkFlow.com INDIANA UNIVERSITY ATHLETICS Agent/Advisor Registration Application Office of Compliance Services III. : MLBPA, NBPA, NFLPA, USATF, WNBPA . *Please check all that apply: (WNBPA): 1.) If yes, please provide the following (as an attachment to this application) a) Nature of the complaint or charge; b) Date of the alleged violation; and c) Result or status of the investigation (including action taken and the authority imposing the action). 2.) Please attach a list of all employees in your agency. 3.) Below, please list the names of any agencies or individuals with whom you have a joint venture. Name of Agency or Individual: Service(s) Provided: IV. Office of the Indiana Attorney General Athlete Agent Certificate of Registration (Athlete Agents Only): Every athlete agent applying to work with IU student-athletes must be registered with the Office of the Indiana Attorney General Consumer Protection Division/Professional Licensing Agency. A copy of an Indiana agent registration or notice of pending registration must be included for all athlete agents. Are you currently registered with the Office of the Indiana Attorney General? If no, do you have a registration pending approval with the Office of the Indiana Attorney General? Have you ever been disciplined or cited for a violation of a state code/statute regulating athlete agents? a) Nature of the complaint or charge; b) Date of the alleged violation; and c) Result or status of the investigation (including action taken and the authority imposing the action). Effective Date: Expiration Date: American LegalNet, Inc. www.FormsWorkFlow.com INDIANA UNIVERSITY ATHLETICS Agent/Advisor Registration Application Office of Compliance Services V. Business Services Offered: Please indicate the services you or your company offers to athletes (check all that apply). Arbitration 1.) Do you offer separate contracts for each service? 2.) Are you currently registered under any of the following: The Securities and Exchange Commission? The Investment Advisers Act? The Financial Information Services Agency (FISA)? If yes, please explain: 4.) Are you bonded? If yes, please provide the amount of bond, company, and address: 5.) Do you refer players to others for services (e. g., financial planning, disability insurance, etc.)? If yes, list firm names, addresses, phone numbers, and services you refer: Yes 6.) Do you receive a fee for referrals? Yes If yes, please explain the basis for any such fees: 7.) Do you have an ownership interest; wholly or partially finance; or directly or indirectly exercise control of any firm or organization that provides services for players upon your referral? If yes, please identify the firms, addresses, phone number, services, and your relationship to them: 8.) Explain your fee structure for each service in detail, including expenses billed to your clients above and beyond your standard percentage (if needed, please attach the explanation to this application): American LegalNet, Inc. www.FormsWorkFlow.com INDIANA UNIVERSITY ATHLETICS Agent/Advisor Registration Application Office of Compliance Services VI. Names of IU Clients Please list the names of current and former clients from IU: VII. Professional Background: 1.) Please list any occupational or professional licenses or bar admissions you have obtained other than college or graduate school degrees (ex. CPA, Charter Life Underwriter, etc.), including dates obtained. Indicate the status of any for which applications are currently pending: 2.) If you have ever been suspended, reprimanded, censured, or otherwise disciplined or disqualified as a member of any professional organization, or as a public office holder, please provide the action taken, dates, authority imposing the action, and their address: American LegalNet, Inc. www.FormsWorkFlow.com INDIANA UNIVERSITY ATHLETICS Agent/Advisor Registration Application Office of Compliance Services VIII.Certification: I have attached with this application the following required forms or information for all athlete agents/advisors: Copies of valid, current registrations with player associations A copy of a valid, current Athlete Agent Certificate of Registration with the Office of the Indiana Attorney General A client list from the last three (3) years including contact information and years of representation A copy of my standard representa Agent/advisor registration applications will not be completed until all the required items above have been received. You may also send any promotional brochures or other information that you would like to have placed in your file accessible by our student athletes, coaches, and staff. I, , hereby apply to Indiana University, for registration to participate in the professional sports education programs for Indiana University student-athletes. By signing below, I certify that the above information is true, correct, and complete to the best of my knowledge. Further, I certify that I will notify the Indiana University Department of Intercollegiate Athletics (via the liaison listed below) before having contact with a student-athlete who has eligibility remaining and is enrolled at Indiana University, the student-, and/or coach. I affirm that I have reviewed the NCAA rules and regulations that accompany this form and have not/will not engage(d) in any activity that would jeopardize a student--athlete. I also understand that failure to comply with the terms of this registration, the laws of the State of Indiana, and applicable NCAA legislation may result in initiation of legal proceedings against me by the University and/or State of Indiana. In the event your information or situation changes, please contact the Office of Compliance Services so that we may update your registration. Applicant Name: Applicant Signature: Date: Return Completed Application To : Indiana University Agent/AdvisorProgram Attention: Office of Compliance Services Indiana University Memorial Stadium 1001 E. 17th St. Bloomington, IN 47408 @i.edu IU Office of Compliance Services Use Only: Date of Review: I U Registration Expires: OIAG Status: Approved Denied OIAG Registration Expires: American LegalNet, Inc. www.FormsWorkFlow.com