AGENT/ADVISOR REGISTRATION APPLICATION
If you are interested in representing a Butler University student-athlete in professional sports negotiations, you must complete this form in its entirety. The completion of this form is required for initial registration in the Butler University Athlete-Agent Program. Agents/advisors who have already registered with Butler must submit a Registration Renewal Form every two years in order to remain active in the Butler University Athlete-Agent Program.
General Information (Please print or type) Name: SS#:
Date of Birth: _____________________ Phone: Check One:
Home
Cell
Name of Firm/Agency: Website of Firm/Agency: Business Address: City
State
Zip
Business Phone: Email Address: Education High School: City
State
City
State
City
State
Month/Year Graduated: College: Month/Year Graduated: Degree(s) Awarded and Year: Graduate/Legal: Degree(s) Awarded and Year: List of Bars you have been admitted to: State Date State Date State Date
Member in good standing? Yes Member in good standing? Yes Member in good standing? Yes
Have you ever been subject to disciplinary action either privately or publicly by any bar? Yes No If yes, which state(s)? Date:
Other Qualifications or Information Current Membership in professional organizations:
No No No
Occupational or professional licenses and date obtained:
Experience Number of years as a player-agent: Sports in which you currently represent athletes and total number of athletes in each sport:
Previous Employment (last two positions and dates of employment) Firm: Position/Date: Address: City:
State:
Firm: Address:
Position/Date: City:
State:
References Name: Firm: Address:
Position: Phone: City:
State:
Name: Firm: Address:
Position: Phone: City:
State:
Name: Firm: Address:
Position: Phone: City:
State:
Indiana Athlete Agent Registration All agents applying for registration to communicate with Notre Dame student-athletes must be registered with the State of Indiana. A copy of such registration, or a notice of pending registration, must be included with this application. I am registered as an athlete agent with the State of Indiana. My application is pending approval by the State of Indiana. Citations: Have you ever been disciplined or cited for a violation of any statute regulating athlete agents? Yes No If yes, please provide a detailed explanation including the nature of the charge, date of the alleged violation, and result or status of the investigation, including action taken, and the authority imposing the action. Attach additional sheet(s) if necessary.
Players’ Association Registrations/Certifications Major League Baseball Players’ Association ( MLBPA)
Effective Date:
Expiration Date:
National Football League Players’ Association ( NFLPA)
Effective Date:
Expiration Date:
National Basketball Players’ Association ( NBPA)
Effective Date:
Expiration Date:
Federation Internationale de Football Association (FIFA)
Effective Date:
Expiration Date:
Women’s Basketball Players’ Association ( WNBPA)
Effective Date:
Expiration Date:
Other:
Effective Date:
Expiration Date:
Have you ever been disciplined or cited for a violation of a players’ association regulation governing athlete agents?
Yes No If yes, please attach an additional sheet(s) providing a detailed explanation including the nature of the charge; date of the alleged violation; and result or status of the investigation, including action taken, and the authority imposing the action.
Professional Services General services performed for client-athletes (check all that apply and indicate fee charged): Playing Contract Negotiations: Endorsement Contract Negotiations: Marketing Services: Financial Planning: Legal Assistance: Money Management: Tax Consulting:
Yes Yes Yes Yes Yes Yes Yes
No No No No No No No
Hourly fee or percentage: Hourly fee or percentage: Hourly fee or percentage: Hourly fee or percentage: Hourly fee or percentage: Hourly fee or percentage: Hourly fee or percentage:
For the services you perform for client-athletes, list the names and addresses of individuals, firms or agencies who assist in providing these services. Use additional sheets if necessary:
Name
City
State
Name
City
State
Name
City
State
Name
City
State
In receiving compensation for contract negotiation services, do you receive payment “up front” or are your payments received as the player is compensated?
Names of any athletes including Butler University athletes (or all clients, if fewer than 10) you previously or currently represent and, in team sports, the team/league to which each athlete is currently under contract and name of team representative with whom you negotiated the 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 client-athletes in each sport. Use additional sheets if necessary:
Player Name
Team
Clients Phone
Team Representative
Please indicate which current Butler University student-athlete(s) you plan to contact in the upcoming year:
Do you earn income from work performed in some capacity other than as a player-agent? Yes No If yes, describe other occupation(s) or service(s) for which you are paid:
What proximate percentage of your total work time is consumed as a player-agent?
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 Compliance Office before the first contact with a student-athlete who has eligibility remaining in any sport and is enrolled in Butler University or before the first contact with the student-athlete’s coach and that I have reviewed the NCAA rules and regulations that accompany this form. I will not and/or have not engaged in any activity prior to a student-athlete’s agreement to be represented that would otherwise jeopardize the student-athlete’s eligibility. I also understand that failure to comply with the terms of this certification and the applicable NCAA legislation, BIG EAST, and Indiana Agent Laws may result in the initiation of legal proceedings by Butler University against me and the assessment of civil and/or criminal penalties to me. Signature:
Date:
Return Completed Form To:
Molly Sullivan Compliance Office 510 West 49th Street Indianapolis, IN 46208
Phone: (317) 940-9630 Email:
[email protected] --------------------------------------------------------------------------Butler University Athletics Compliance Office Use Only
Compliance Office Approval
Date