Application For Registration As An Athlete Agent

Elaine F. Marshall Secretary of State NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE P.O. Box 29622 Raleigh, NC 27626-0622 WWW.SOSNC.COM 919-733-3924 APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT N.C.G.S. §§ 78C-89(a)(1)-(12) ­ APPLICATION FORM *APPLICATION MUST BE TYPED OR PRINTED* * PLEASE NOTE THAT THIS APPLICATION MAY BE SUBMITTED ONLY IN THE NAME OF THE INDIVIDUAL SEEKING REGISTRATION AS AN ATHLETE AGENT. "INDIVIDUAL" REFERS TO A SINGLE HUMAN BEING. * *APPLICATION FEES ARE NONREFUNDABLE* Revised March 2011 Date: CHECK ONE: INITIAL APPLICATION ? RENEWAL APPLICATION ? SECTION 1. GENERAL INFORMATION 1) APPLICANT'S NAME: 2) NAME OF APPLICANT'S BUSINESS OR EMPLOYER: 3) ADDRESS OF APPLICANT'S PRINCIPAL PLACE OF BUSINESS STREET ______________________________________________________________________________ CITY STATE ZIP CODE Telephone: tT Email: 1 American LegalNet, Inc. www.FormsWorkFlow.com 4) SUPPLY THE NAMES AND ADDRESSES OF THREE INDIVIDUALS NOT RELATED TO THE APPLICANT WHO ARE WILLING TO SERVE AS REFERENCES: _______________________________________________________________________________ A) NAME PHONE NUMBER -----------------------------------------------------------------------------------------------------------------------------------------------ADDRESS _______________________________________________________________________________________________ B) NAME PHONE NUMBER -----------------------------------------------------------------------------------------------------------------------------------------------ADDRESS _______________________________________________________________________________________________ C) NAME PHONE NUMBER -----------------------------------------------------------------------------------------------------------------------------------------------ADDRESS SECTION 2. APPLICANT BACKGROUND AND EXPERIENCE 5) DESCRIBE THE APPLICANT'S EDUCATIONAL BACKGROUND AS IT RELATES TO HIS OR HER ACTIVITIES AS AN ATHLETE AGENT (ATTACH ADDITIONAL SHEETS AS NEEDED.) A) EDUCATIONAL INSTITUTION DATES ATTENDED -----------------------------------------------------------------------------------------------------------------------------------------------DEGREE, IF ANY RELATED COURSES _______________________________________________________________________________________________ B) EDUCATIONAL INSTITUTION DATES ATTENDED -----------------------------------------------------------------------------------------------------------------------------------------------DEGREE, IF ANY RELATED COURSES 2 American LegalNet, Inc. www.FormsWorkFlow.com 6) DESCRIBE THE APPLICANT'S FORMAL TRAINING AS AN ATHLETE AGENT, INCLUDING SEMINARS, CERTIFICATIONS, AND OTHER RELATED EXPERIENCES (ATTACH ADDITIONAL SHEETS AS NEEDED.): 7) DESCRIBE THE APPLICANT'S PRACTICAL EXPERIENCE AS AN ATHLETE AGENT (ATTACH ADDITIONAL SHEETS AS NEEDED.): 3 American LegalNet, Inc. www.FormsWorkFlow.com DIRECTIONS. Make copies of this page as needed to provide the requested information. Please indicate the total number of copied pages attached to your submission in the Oath/Affirmation. 8) STATE ANY BUSINESS OR OCCUPATION ENGAGED IN BY THE APPLICANT FOR THE FIVE YEARS IMMEDIATELY PRECEDING THE DATE OF SUBMISSION OF THIS APPLICATION: A) BUSINESS NAME TITLE DATES IN POSITION -----------------------------------------------------------------------------------------------------------------------BUSINESS ADDRESS -----------------------------------------------------------------------------------------------------------------------SUPERVISOR'S NAME BUSINESS PHONE# _______________________________________________________________________________ B) BUSINESS NAME TITLE DATES IN POSITION -----------------------------------------------------------------------------------------------------------------------BUSINESS ADDRESS -----------------------------------------------------------------------------------------------------------------------SUPERVISOR'S NAME BUSINESS PHONE# _______________________________________________________________________________ C) BUSINESS NAME TITLE DATES IN POSITION -----------------------------------------------------------------------------------------------------------------------BUSINESS ADDRESS -----------------------------------------------------------------------------------------------------------------------SUPERVISOR'S NAME BUSINESS PHONE# _______________________________________________________________________________________________ D) BUSINESS NAME TITLE DATES IN POSITION -----------------------------------------------------------------------------------------------------------------------BUSINESS ADDRESS -----------------------------------------------------------------------------------------------------------------------SUPERVISOR'S NAME 4 BUSINESS PHONE# American LegalNet, Inc. www.FormsWorkFlow.com DIRECTIONS. Make copies of this page as needed to provide the requested information. Please indicate the total number of copied pages attached to your submission in the Oath/Affirmation. 9) INDIVIDUALS FOR WHOM THE APPLICANT HAS ACTED AS AN ATHLETE AGENT Provide the NAME, SPORT, and LAST KNOWN TEAM for EACH individual for whom you have acted as an athlete agent during the FIVE years immediately preceding the date of submission of your application for registration as an athlete agent in North Carolina. ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates of Representation ______________________________________________________________________________ ___ Name Sport Last Known Team Dates