Athlete Agent Notice Of Conviction {2510}

Form #2510 Rev. 12/2011 This space reserved for office use Submit to: SECRETARY OF STATE Registrations Unit P O Box 13550 Austin, TX 78711-3550 512-475-0775 512-475-2815 ­ Fax Filing Fee: None ATHLETE AGENT NOTICE OF CONVICTION This form may be used to notify the secretary of state of a conviction of a crime, regardless of where the conviction occurred, if in Texas the crime would be an offense other than a Class C misdemeanor. Section 2051.109, Occupations Code, requires a registered athlete agent to notify the secretary of state in writing not later than 30 days after the date of conviction. Failure to notify the secretary of state as required by § 2051.109 may be grounds for disciplinary action. 1. Name of Agent: 2. Agent ID Number: 3. Principal Business Address: Street OR City Registration Number: State Zip I have been convicted of a crime that in Texas would be an offense other than a Class C misdemeanor. Copies of related documentation, including court order and sentence, and papers pertaining to release from probation, if applicable, are attached. The following is a statement of (i) the nature, circumstances, date, and location, and (ii) whether the matter is on appeal. Execution Date: Signature of athlete agent Printed or typed name Form 2510 1 American LegalNet, Inc. www.FormsWorkFlow.com