UNIVERSITY OF WASHINGTON

Department of Intercollegiate Athletics Agent Registration Application

The completion of this form in its entirety is required to apply for registration with the University of Washington (UW) Student-Athlete/Agent Program. Registration will be valid for two years following approval of this application. Please note that disclosure of this information is requested pursuant to Chapter 19.225 RCW, the State of Washington Athlete Agent Act.

GENERAL INFORMATION (Please type or print):

Name: Email address: Home address: City: State: Name of Firm/Agency/Corporation (If applicable): Business Address: City: State: Phone: Phone: Zip:

Zip:

Business Phone:

Section 1: With respect to a corporation employing the athlete agent, please list the name(s) of the officers, directors, any shareholders of the corporation with five percent or greater interest and individuals who assist you in recruitment of client athletes (please use additional sheets if needed): Name Title Address

With respect to the athlete agents business if it is not a corporation, please list the name(s) of the partners, officers, associates, profit-sharers or individuals who assist you in recruitment of client athletes. (Please use additional sheets if needed): Name Title Address

Section 2: Please list any athlete agent and/or individuals from the names listed in Section 1 who have been convicted of a crime that, if committed in this state, would be a felony or a crime involving moral turpitude, and please identify the crime: Name Crime

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Please list any athlete agent and/or individual listed in Section 1 whose conduct has ever resulted in: (i) any sanction on a student-athlete or educational institution; (ii) any suspension of a student-athlete; or (iii) any declaration of ineligibility of a student-athlete to participate in intercollegiate athletics. Name Conduct

Have any sanctions, suspensions, or disciplinary actions been imposed on or taken against you or any other person named No in Section 1 arising out of occupational or professional misconduct? Yes If yes, please explain:

Have you ever been denied an initial or renewal application for registration or licensure as an athlete agent in any state or No had such registration/licensure revoked or suspended? Yes If yes, please explain:

Have any of the individuals listed in Section 1 ever been denied an initial or renewal application for registration or licensure as an athlete agent in any state or had such registration/licensure revoked or suspended? Yes No If yes, please explain:

EDUCATION:
High School: College (undergraduate): Degree(s) and Year Graduated: Graduate/Law School: Admitted to the Bar: Yes No City City City State State State State Date Admitted:

ADDITIONAL FORMAL TRAINING AS AN ATHLETE AGENT:

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EXPERIENCE:
Number of years of experience as an athlete agent: Sports in which you currently represent athletes and total number of athletes in each sport:

OTHER QUALIFICATIONS:
Current membership in professional organizations:

Occupational or professional licenses (e.g., certified public accountant) and date obtained:

Are you currently registered with any state(s) as a player-agent? Yes If yes, please list the state(s) in which you are registered: Are you currently certified by the NFLPA? Are you currently certified by the NBPA? Are you currently certified by the MLBPA? Are you currently certified by any other league? Yes Yes Yes Yes

No

No No No No

Permanent Provisional (Circle One) Permanent Provisional (Circle One) Permanent Provisional (Circle One) (If yes, please list): Permanent Provisional (Circle One) Permanent Provisional (Circle One)

PROFESSIONAL SERVICES:
General services performed for clients (check those that apply and please indicate fee or percentage charged): Playing Contract Negotiations: Yes Endorsement Contract Negotiation: Yes Legal Assistance: Yes Financial Planning: Yes Tax Consulting: Yes Money Management: Yes Other: No Amount of fee/percentage: No Amount of fee/percentage: No Amount of fee/percentage: No Amount of fee/percentage: No Amount of fee/percentage: No Amount of fee/percentage: Amount of fee/percentage:

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For services you perform as an athlete agent, list the names and addresses of individuals, firms, or agencies that assist you in providing these services in recruitment of client athletes:

Name

City

State

Phone

Name

City

State

Phone

Name

City

State

Phone

Name

City

State

Phone

Name

City

State

Phone

In receiving compensation for contract negotiations services, do you receive payment up front or do you receive payments as the player is compensated? _______________

Please list the names of the athletes, including UW former student-athletes, whom you have previously represented or currently represent who are currently under contract with a sports team/league. Please also provide the name of the team representative with whom you negotiated these athletes contracts as an athlete agent during the five years preceding the date of execution of this athlete agent disclosure form. Write none if you currently do not represent any athlete. If you represent athletes in more than one sport, please provide this information for each sport. Use additional sheets if necessary: Player Name Team Client Phone Team Representatives

Please indicate which current UW student-athlete(s) you plan to contact?

Do you earn income from work performed in some capacity other than an athlete agent? Yes If yes, please describe other occupation(s) or service(s) for which you are paid:

No

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PREVIOUS EMPLOYMENT WITHIN THE PAST FIVE YEARS (Please attach an additional sheet if necessary):
Firm: Address: City State Position/Dates: ________ Zip

Firm: Address:

Position/Dates: ________ City State Zip

THREE PERSONAL REFERENCES (Not related to the applicant):

Name: Address: ________ City Phone:

State

Zip

Name: Address: _________ City

Phone:

State

Zip

Name: Address: City

Phone: ________ State

Zip

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I certify that the information provided is true, correct and complete to the best of my knowledge. Furthermore, before I make any contact with any student-athlete enrolled at UW who has eligibility remaining in his/her sport(s), I will notify in writing: (1) the student-athletes Head Coach; and (2) either the UW Director of Athletics or the UW Compliance Office. In addition, I have reviewed the NCAA rules related to agents and amateurism, the UW policies related to agents and the State of Washington Athlete Agent Act (referred to collectively as Rules, Policies and Statutes). I understand and agree to follow these Rules, Policies and Statutes in the future, and I represent that I have not engaged in any past behavior that has violated these Rules, Policies and Statutes or that has jeopardized the eligibility of any student-athlete. I understand that the failure to comply with these Rules, Policies and Statutes may subject me to civil and/or criminal liability and may result in a decision prohibiting me from or any person(s) representing my firm firm/agency from contacting UW student-athletes with remaining eligibility.

(Print Name)

(Date)

(Signature)

Return Completed Form To:

Marilou Michelena University of Washington Department of Intercollegiate Athletics Compliance Office Box 354070 Seattle, Washington 98195 Fax: 206-616-5813 Email: mariloum@u.washington.edu

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University of Washington Agent Application