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Agent Registration Form HUSKIE ATHLETIC COMPLIANCE OFFICE
Agent Information Full Name: Firm/Agency:
Position:
Address:
City:
Phone:
State:
Email:
Zip:
Fax:
Website: I am a certified agent, in good standing as of the date of completion of this form, with the following: (check all that apply) National Football League Players Association
Effective Date:
Expiration Date:
National Basketball Players Association
Effective Date:
Expiration Date:
Major League Baseball Players Association
Effective Date:
Expiration Date:
Major League Soccer Players Union
Effective Date:
Expiration Date:
Other:
Effective Date:
Expiration Date:
Other:
Effective Date:
Expiration Date:
Educational Background College/University: School:
Degree:
Date Awarded:
Degree:
Date Awarded:
Degree:
Date Awarded:
Graduate/Legal: School: Additional Schooling: School:
NIU Student-Athletes Please list below the Northern Illinois University student-athletes that you plan to contact in the upcoming year: Sport
Name
1
Professional Services A. Professional services and general services performed for client-athlete, and associated fees, (check all that apply): Playing Contract Negotiations Fee Rate:
Tax Consulting
Fee Rate:
Legal Assistance
Fee Rate:
Money Management
Fee Rate:
Financial Planning
Fee Rate:
Estate Planning
Fee Rate:
Endorsement Negotiations
Fee Rate:
Other:
Fee Rate:
Insurance
Fee Rate:
Other:
Fee Rate:
B. Please indicate whether your organization does the following: 1. Do you offer separate contracts for each service?
Yes
No
2. Do you handle athletes' funds?
Yes
No
Yes
No
3. Are you currently registered under the Investment Advisor's Act?
Yes
No
4. Do you receive a fee from any individual(s)/firm(s) for referral?
Yes
No
If yes, are you bonded?
If yes, what is the basis of any fee?
5. If you assist athletes with securing the services you do not provide, please indicate below the individual(s)/firm(s) to which you customarily refer athletes for each service: Services:
Firm Name:
Firm Address:
Firm Phone Number:
Services:
Firm Name:
Firm Address:
Firm Phone Number:
Services:
Firm Name:
Firm Address:
Firm Phone Number:
Services:
Firm Name:
Firm Address:
Firm Phone Number:
C. General athlete-agent agreement details: 1. How and when are you paid? 2. What is the duration of your agreements? 3. What happens if the agreement is terminated? 4. What happens to the agreement if athlete is waived from a team?
Please attach a copy of your/your firm's standard agent contract which would authorize a person to negotiate or solicit any professional sport services on behalf of a student-athlete/client.
2
Lawyers/Law Graduates (Only fill out if applicable) A. Please List the jurisdictions in which you have been admitted to the bar and the dates of admission: Jurisdiction:
Date of Admission:
Status:
Jurisdiction:
Date of Admission:
Status:
B. If you have any applications for bar admission currently pending, please state where you have applied and the status of that application: Jurisdiction:
Status:
Jurisdiction:
Status:
Professional Background A. Please list the state(s) in which you are currently registered or have applied to be registered pursuant to the any state statutes regulating athlete agents or advisors: State:
Status of Registration:
State:
Status of Registration:
State:
Status of Registration:
B. List your employment history for the last five (5) years: 1. Current Employer:
Date of Employment:
Job Title/Position: Address:
Phone:
Supervisor Name:
Phone:
2. Past Employer:
Date of Employment:
Job Title/Position: Address:
Phone:
Supervisor Name:
Phone:
3. Past Employer:
Date of Employment:
Job Title/Position: Address:
Phone:
Supervisor Name:
Phone:
C. List the number of years you have been an athlete agent, sports in which you currently represent clients, and number of clients in each sport: Number of years as an athlete agent: Sports in which you currently represent athletes: Sport:
Number of Athletes Represented:
Sport:
Number of Athletes Represented:
Sport:
Number of Athletes Represented:
D. Provide information for three (3) current or previous clients you have had in the past five (5) years: Client:
Current 3
Previous
Email or Phone Number:
Team and League:
Client: Email or Phone Number:
Current
Previous
Current
Previous
Team and League:
Client: Email or Phone Number:
Team and League:
Professional Responsibility A. Please provide any memberships that you have in business or professional organizations which directly relate to your occupation or profession: Organization:
Date of Membership:
Organization:
Date of Membership:
B. Please list any occupational or professional licenses or other similar credentials (e.g., Certified Public Accountant, Chartered Life Underwriter, Registered Investment Advisor) you have obtained other than college or graduate school degrees, including the date: License/Credential:
Date Obtained:
License/Credential:
Date Obtained:
C. If you have ever been denied an occupational or professional license, franchise or other similar credentials for which you applied, please explain fully: Denied License/Credential:
Reason for Denial:
Denied License/Credential:
Reason for Denial:
D. Please describe and indicate the status of any applications you currently have pending for an occupational professional license, franchise or other similar credentials: License/Credential:
Licensing Authority:
License/Credential:
Licensing Authority:
E. If you have ever been disbarred, suspended, reprimanded, censured, or otherwise disciplined or disqualified as a member of any profession, or as a public office holder, please complete the following: Action:
Date of Occurrence:
Disciplining Authority and Address : Action:
Date of Occurrence:
Disciplining Authority and Address : F. If any charges or complaints are currently pending against you regarding your conduct as a member of any profession, or as a public office holder, please provide the following information: Charge/Complaint Pending:
Authority Considering Charge: 4
Address of Authority : Charge/Complaint Pending:
Authority Considering Charge:
Address of Authority : G. If you have ever been disciplined or cited for a violation of a state statute regulating athlete agents, please complete the following: Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
H. If you have ever been involved in or accused of participating in any action alleged to have been in violation of the rules of the NCAA, any conference, any university or college, any players association, and/or any sports club, league, federation, or team, please complete the following: Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
I. If you have ever been convicted of or plead guilty to a criminal charge, other than minor traffic violations, please complete the following: Charge/complaint:
Date of Conviction:
Criminal Authority :
Punishment Assessed:
Charge/complaint:
Date of Conviction:
Criminal Authority :
Punishment Assessed:
J. If you have ever been a defendant in any civil proceedings, including bankruptcy proceedings, in which allegations of fraud, misrepresentation, embezzlement, misappropriation of funds, conversion, breach of fiduciary duty, forgery, or legal malpractice were made against you, please describe fully and indicate the date and results of the civil proceeding(s) in question: Complaint: Result/Status:
Date of Proceedings :
Complaint: Result/Status:
Date of Proceedings :
References Please provide a list of three (3) character references who are not related to you, not engaged in business with you, have known you for at least five (5) years, and can attest to your character. For each, provide the following information: 1. Name: Relationship: Address:
Phone Number: 5
2. Name:
Relationship:
Address:
Phone Number:
3. Name:
Relationship:
Address:
Phone Number:
Agreement I agree that all statements, agreements, and representations made in this application and its attachments are accurate as of my application date and are made for the benefit of Northern Illinois University and its student-athletes, both present and future, and that the information herein is public information and may be provided by Northern Illinois University to its student-athletes, families, and others. I also agree to provide the Huskie Athletic Compliance Office (HACO) with copies of any correspondence sent directly to any Northern Illinois University student-athlete.
Applicant Signature
Date
Compliance Approval
Compliance Signature
Date
Approval email sent to coaches/Sport AD/ABO/HACO/student-athletes
6
HACO 6/24/2016
Submit by Email
Agent Registration Form HUSKIE ATHLETIC COMPLIANCE OFFICE
Agent Information Full Name: Firm/Agency:
Position:
Address:
City:
Phone:
State:
Email:
Zip:
Fax:
Website: I am a certified agent, in good standing as of the date of completion of this form, with the following: (check all that apply) National Football League Players Association
Effective Date:
Expiration Date:
National Basketball Players Association
Effective Date:
Expiration Date:
Major League Baseball Players Association
Effective Date:
Expiration Date:
Major League Soccer Players Union
Effective Date:
Expiration Date:
Other:
Effective Date:
Expiration Date:
Other:
Effective Date:
Expiration Date:
Educational Background College/University: School:
Degree:
Date Awarded:
Degree:
Date Awarded:
Degree:
Date Awarded:
Graduate/Legal: School: Additional Schooling: School:
NIU Student-Athletes Please list below the Northern Illinois University student-athletes that you plan to contact in the upcoming year: Sport
Name
1
Professional Services A. Professional services and general services performed for client-athlete, and associated fees, (check all that apply): Playing Contract Negotiations Fee Rate:
Tax Consulting
Fee Rate:
Legal Assistance
Fee Rate:
Money Management
Fee Rate:
Financial Planning
Fee Rate:
Estate Planning
Fee Rate:
Endorsement Negotiations
Fee Rate:
Other:
Fee Rate:
Insurance
Fee Rate:
Other:
Fee Rate:
B. Please indicate whether your organization does the following: 1. Do you offer separate contracts for each service?
Yes
No
2. Do you handle athletes' funds?
Yes
No
Yes
No
3. Are you currently registered under the Investment Advisor's Act?
Yes
No
4. Do you receive a fee from any individual(s)/firm(s) for referral?
Yes
No
If yes, are you bonded?
If yes, what is the basis of any fee?
5. If you assist athletes with securing the services you do not provide, please indicate below the individual(s)/firm(s) to which you customarily refer athletes for each service: Services:
Firm Name:
Firm Address:
Firm Phone Number:
Services:
Firm Name:
Firm Address:
Firm Phone Number:
Services:
Firm Name:
Firm Address:
Firm Phone Number:
Services:
Firm Name:
Firm Address:
Firm Phone Number:
C. General athlete-agent agreement details: 1. How and when are you paid? 2. What is the duration of your agreements? 3. What happens if the agreement is terminated? 4. What happens to the agreement if athlete is waived from a team?
Please attach a copy of your/your firm's standard agent contract which would authorize a person to negotiate or solicit any professional sport services on behalf of a student-athlete/client.
2
Lawyers/Law Graduates (Only fill out if applicable) A. Please List the jurisdictions in which you have been admitted to the bar and the dates of admission: Jurisdiction:
Date of Admission:
Status:
Jurisdiction:
Date of Admission:
Status:
B. If you have any applications for bar admission currently pending, please state where you have applied and the status of that application: Jurisdiction:
Status:
Jurisdiction:
Status:
Professional Background A. Please list the state(s) in which you are currently registered or have applied to be registered pursuant to the any state statutes regulating athlete agents or advisors: State:
Status of Registration:
State:
Status of Registration:
State:
Status of Registration:
B. List your employment history for the last five (5) years: 1. Current Employer:
Date of Employment:
Job Title/Position: Address:
Phone:
Supervisor Name:
Phone:
2. Past Employer:
Date of Employment:
Job Title/Position: Address:
Phone:
Supervisor Name:
Phone:
3. Past Employer:
Date of Employment:
Job Title/Position: Address:
Phone:
Supervisor Name:
Phone:
C. List the number of years you have been an athlete agent, sports in which you currently represent clients, and number of clients in each sport: Number of years as an athlete agent: Sports in which you currently represent athletes: Sport:
Number of Athletes Represented:
Sport:
Number of Athletes Represented:
Sport:
Number of Athletes Represented:
D. Provide information for three (3) current or previous clients you have had in the past five (5) years: Client:
Current 3
Previous
Email or Phone Number:
Team and League:
Client: Email or Phone Number:
Current
Previous
Current
Previous
Team and League:
Client: Email or Phone Number:
Team and League:
Professional Responsibility A. Please provide any memberships that you have in business or professional organizations which directly relate to your occupation or profession: Organization:
Date of Membership:
Organization:
Date of Membership:
B. Please list any occupational or professional licenses or other similar credentials (e.g., Certified Public Accountant, Chartered Life Underwriter, Registered Investment Advisor) you have obtained other than college or graduate school degrees, including the date: License/Credential:
Date Obtained:
License/Credential:
Date Obtained:
C. If you have ever been denied an occupational or professional license, franchise or other similar credentials for which you applied, please explain fully: Denied License/Credential:
Reason for Denial:
Denied License/Credential:
Reason for Denial:
D. Please describe and indicate the status of any applications you currently have pending for an occupational professional license, franchise or other similar credentials: License/Credential:
Licensing Authority:
License/Credential:
Licensing Authority:
E. If you have ever been disbarred, suspended, reprimanded, censured, or otherwise disciplined or disqualified as a member of any profession, or as a public office holder, please complete the following: Action:
Date of Occurrence:
Disciplining Authority and Address : Action:
Date of Occurrence:
Disciplining Authority and Address : F. If any charges or complaints are currently pending against you regarding your conduct as a member of any profession, or as a public office holder, please provide the following information: Charge/Complaint Pending:
Authority Considering Charge: 4
Address of Authority : Charge/Complaint Pending:
Authority Considering Charge:
Address of Authority : G. If you have ever been disciplined or cited for a violation of a state statute regulating athlete agents, please complete the following: Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
H. If you have ever been involved in or accused of participating in any action alleged to have been in violation of the rules of the NCAA, any conference, any university or college, any players association, and/or any sports club, league, federation, or team, please complete the following: Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
Charge/complaint:
Date of Alleged Violation:
Disciplining Authority :
Result/Status of Investigation:
I. If you have ever been convicted of or plead guilty to a criminal charge, other than minor traffic violations, please complete the following: Charge/complaint:
Date of Conviction:
Criminal Authority :
Punishment Assessed:
Charge/complaint:
Date of Conviction:
Criminal Authority :
Punishment Assessed:
J. If you have ever been a defendant in any civil proceedings, including bankruptcy proceedings, in which allegations of fraud, misrepresentation, embezzlement, misappropriation of funds, conversion, breach of fiduciary duty, forgery, or legal malpractice were made against you, please describe fully and indicate the date and results of the civil proceeding(s) in question: Complaint: Result/Status:
Date of Proceedings :
Complaint: Result/Status:
Date of Proceedings :
References Please provide a list of three (3) character references who are not related to you, not engaged in business with you, have known you for at least five (5) years, and can attest to your character. For each, provide the following information: 1. Name: Relationship: Address:
Phone Number: 5
2. Name:
Relationship:
Address:
Phone Number:
3. Name:
Relationship:
Address:
Phone Number:
Agreement I agree that all statements, agreements, and representations made in this application and its attachments are accurate as of my application date and are made for the benefit of Northern Illinois University and its student-athletes, both present and future, and that the information herein is public information and may be provided by Northern Illinois University to its student-athletes, families, and others. I also agree to provide the Huskie Athletic Compliance Office (HACO) with copies of any correspondence sent directly to any Northern Illinois University student-athlete.
Applicant Signature
Date
Compliance Approval
Compliance Signature
Date
Approval email sent to coaches/Sport AD/ABO/HACO/student-athletes
6
HACO 6/24/2016
