LOYOLA UNIVERSITY CHICAGO ATHLETIC OFFICE OF
LOYOLA UNIVERSITY CHICAGO ATHLETIC OFFICE OF COMPLIANCE AGENT REGISTRATION FORM I.
Legal Name of Applicant: Last
II.
First
Middle
Employment Information: If currently employed with a particular firm or agency as a player‐agent, please indicate: Name of Firm/Agency: Business Address:
Business Phone:
Fax Number:
Email Address: If self - employed, please indicate nature of business: Nature of Business: Business Address:
Business Phone:
Fax Number:
Email Address:
III.
Education: College (undergraduate) Institution:
City & State:
Degree Awarded and Year Graduated: Law School or Other Graduate Schools: Institution: Degree Awarded and Year Graduated:
City & State:
LOYOLA UNIVERSITY CHICAGO ATHLETIC OFFICE OF COMPLIANCE IV.
Professional References Name:
Phone Number:
Business Address:
Email Address: Name:
Phone Number:
Business Address:
Email Address: Name:
Phone Number:
Business Address:
Email Address:
V.
Experience Number of years as a player‐agent: Current membership in professional organizations:
Are you currently certified by the NBPA? Yes No
Provisional
Are you currently certified by another professional organization? Name: Yes No Permanent
Provisional
Permanent
Has your license even been suspended, revoked, or put on probation?
Yes
No
If yes, please attach an explanation.
LOYOLA UNIVERSITY CHICAGO ATHLETIC OFFICE OF COMPLIANCE Please identify the name(s) of any athletes, beginning with LUC athletes, whom you currently represent. If the total number of your clients exceeds ten, please list only ten. If a client competes in a team sport, please list the team for which they currently play. Write “None” if you do not currently represent any athletes. Name
VI.
Dates Represented
Team
Professional Services
Player Contract Negotiations Endorsement Contract Negotiations Financial Planning Legal Assistance
Yes
No
I certify that the above information is accurate and true to the best of my knowledge. Further, I certify that I have reviewed the applicable NCAA regulations regarding agents and have not, nor will not, engage in any activities that jeopardize the eligibility of any Loyola University Chicago student‐athlete. Signature:
Date:
Please return completed form, along with a copy of your State of Illinois Agent License, to: Loyola University Chicago Athletics Athletic Office of Compliance Norville Center 6526 N. Winthrop Avenue Chicago, IL 60626 FAX: (773) 508-3884
Office of Compliance Signature:
Date:
FOR OFFICE OF COMPLIANCE USE ONLY: Information has been updated in: Agent Tracking Spreadsheet Notification has been sent to: Agent Coaching Staff
Legal Name of Applicant: Last
II.
First
Middle
Employment Information: If currently employed with a particular firm or agency as a player‐agent, please indicate: Name of Firm/Agency: Business Address:
Business Phone:
Fax Number:
Email Address: If self - employed, please indicate nature of business: Nature of Business: Business Address:
Business Phone:
Fax Number:
Email Address:
III.
Education: College (undergraduate) Institution:
City & State:
Degree Awarded and Year Graduated: Law School or Other Graduate Schools: Institution: Degree Awarded and Year Graduated:
City & State:
LOYOLA UNIVERSITY CHICAGO ATHLETIC OFFICE OF COMPLIANCE IV.
Professional References Name:
Phone Number:
Business Address:
Email Address: Name:
Phone Number:
Business Address:
Email Address: Name:
Phone Number:
Business Address:
Email Address:
V.
Experience Number of years as a player‐agent: Current membership in professional organizations:
Are you currently certified by the NBPA? Yes No
Provisional
Are you currently certified by another professional organization? Name: Yes No Permanent
Provisional
Permanent
Has your license even been suspended, revoked, or put on probation?
Yes
No
If yes, please attach an explanation.
LOYOLA UNIVERSITY CHICAGO ATHLETIC OFFICE OF COMPLIANCE Please identify the name(s) of any athletes, beginning with LUC athletes, whom you currently represent. If the total number of your clients exceeds ten, please list only ten. If a client competes in a team sport, please list the team for which they currently play. Write “None” if you do not currently represent any athletes. Name
VI.
Dates Represented
Team
Professional Services
Player Contract Negotiations Endorsement Contract Negotiations Financial Planning Legal Assistance
Yes
No
I certify that the above information is accurate and true to the best of my knowledge. Further, I certify that I have reviewed the applicable NCAA regulations regarding agents and have not, nor will not, engage in any activities that jeopardize the eligibility of any Loyola University Chicago student‐athlete. Signature:
Date:
Please return completed form, along with a copy of your State of Illinois Agent License, to: Loyola University Chicago Athletics Athletic Office of Compliance Norville Center 6526 N. Winthrop Avenue Chicago, IL 60626 FAX: (773) 508-3884
Office of Compliance Signature:
Date:
FOR OFFICE OF COMPLIANCE USE ONLY: Information has been updated in: Agent Tracking Spreadsheet Notification has been sent to: Agent Coaching Staff
