Athlete Agent Notice Of Decertification {2511}

Form #2511 Rev. 012/2011 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 DECERTIFICATION This form may be used to notify the secretary of state of an agent's decertification as an agent by a national professional sports association that has become final by the conclusion of the appeal process provided by the association. 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 the athlete agent's decertification. 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 The following national professional sports associations have decertified me as an athlete agent: Execution Date: Signature of athlete agent Printed or typed name Form 2511 1 American LegalNet, Inc. www.FormsWorkFlow.com