Ball State Athletics Compliance 6.10.2015 MCC Ball

  Ball  State  University                                                                                                                                                                  Agent  Questionnaire    Athletics  Compliance  Office                                                                                                 Agents:  The  completion  of  this  document  DOES  NOT  SATISFY  THE  INDIANA  STATUTE  requiring  Agents  to  file  with  the   Attorney   General.   Proof   of   filing   with   the   Attorney   General   must   be   submitted   to   the   Ball   State   University   Athletics   Compliance   Office   by   those   individuals   wishing   to   represent   Ball   State   University   student-­‐athletes   in   FUTURE   professional  athletics  careers.     Please  return  this  questionnaire  to:   Pat  Quinn,  Deputy  Athletics  Director  –  Internal  Affairs   Ball  State  University   HP  148-­‐C   Muncie,  IN  47306   or  Fax  to:  (765)  285-­‐6616     BACKGROUND:     Name:                Firm:                       Address:                City/State/Zip:                     Daytime  Phone:              Evening  Phone:                   Fax:                  Email:                           STATEMENT  OF  UNDERSTANDING:     The   following   information   is   provided   as   a   service   to   assist   (insert   student-­‐athlete’s   name   if   applicable)   __________________________________   and/or   Ball   State   University   to   better   understand   the   type   and   kinds   of   services   and   expertise   offered   by   the   respondent   in   preparation   for   a   future   professional   sports   contract.   It   is   acknowledged  by  all  parties  through  this  communication  that  the  responses  are  intended  to  assist  any  student-­‐athlete  in   learning  more  about  the  particular  firm  and  its  agents/representatives.  Part  of  this  process  is  accomplished  by  reference   to   the   information   provided   –   in   other   instances,   by   personal   interview   or   meeting.   Cognizant   of   the   need   to   provide   accurate  and  reliable  information,  those  reviewing  this  material  understand  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   any   additional,   appropriate   documentation.   In   submitting   this   form,   I   voluntarily   agree   to   comply   with   and   be   bound   by   any   applicable   Indiana   State   law.   I   further   understand   by   making   any   false   or   misleading   statement   of   any   nature   in   answering  a  question  on  this  form,  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.           Printed  Name               Signature  

   

   

   

   

   

 

 

 

 

 

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Ball  State  Athletics  Compliance   6.10.2015  MCC