Agent Registration Form - GoHuskies.com

UNIVERSITY OF WASHINGTONDEPARTMENT OF INTERCOLLEGIATE ATHLETICSAGENT REGISTRATION APPLICATIONThe completion of this form in its entirety is required to apply for registration with the University ofWashington (UW) Student-Athlete/Agent Program. Registration will be valid for two years following approvalof 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 print or type)Name:Email address:Phone:Home address:Phone:City: State: Zip:Name of Firm/Agency/Corporation (If applicable):Business Address:City: State: 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 assistyou in recruitment of client athletes (please use additional sheets if needed):Name Title AddressWith respect to the athlete agent’s 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 useadditional sheets if needed):Name Title AddressSection 2: Please list any athlete agent and/or individuals from the names listed in Section 1 who have beenconvicted of a crime that, if committed in this state, would be a felony or a crime involving moral turpitude, andplease identify the crime:NameCrimeUniversity of Washington Athletics Compliance

Please list any athlete agent and/or individual listed in Section 1 whose conduct has ever resulted in: (i) anysanction on a student-athlete or educational institution; (ii) any suspension of a student-athlete; or (iii) anydeclaration of ineligibility of a student-athlete to participate in intercollegiate athletics.NameConductHave any sanctions, suspensions, or disciplinary actions been imposed on or taken against you or any otherperson named in Section 1 arising out of occupational or professional misconduct? Yes NoIf yes, please explain:Have you ever been denied an initial or renewal application for registration or licensure as an athlete agent inany state or had such registration/licensure revoked or suspended? Yes NoIf yes, please explain:Have any of the individuals listed in Section 1 ever been denied an initial or renewal application for registrationor licensure as an athlete agent in any state or had such registration/licensure revoked or suspended?Yes NoIf yes, please explain:Section 3: EducationHigh School: City StateCollege (undergraduate): City StateDegree(s) and Year Graduated:Graduate/Law School: City StateAdmitted to the Bar: Yes No State Date Admitted:Additional formal training as an athlete agentUniversity of Washington Athletics Compliance

ExperienceNumber of years of experience as an athlete agent:Sports in which you currently represent athletes and total number of athletes in each sport:Other QualificationsCurrent 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? YesNoIf yes, please list the state(s) in which you are registered:Are you currently certified by the NFLPA? Yes No Permanent Provisional(Circle One)Are you currently certified by the NBPA? Yes No Permanent Provisional(Circle One)Are you currently certified by the MLBPA? Yes No Permanent Provisional(Circle One)Are you currently certified by any other league? Yes No (If yes, please list below):Permanent Provisional(Circle One)Permanent Provisional(Circle One)Section 3: Professional ServicesGeneral services performed for clients (check those that apply and please indicate fee or percentage charged):Playing Contract Negotiations:Endorsement Contract Negotiation:Legal Assistance:YesYesYesNoNoNoAmount of fee/percentage:Amount of fee/percentage:Amount of fee/percentage:University of Washington Athletics Compliance

Financial Planning:Tax Consulting:Money Management:Other:YesYesYesNoNoNoAmount of fee/percentage:Amount of fee/percentage:Amount of fee/percentage:Amount of fee/percentage:For services you perform as an athlete agent, list the names and addresses of individuals, firms, or agencies thatassist you in providing these services in recruitment of client athletes:Name City State PhoneName City State PhoneName City State PhoneName City State PhoneName City State PhoneIn receiving compensation for contract negotiations services, do you receive payment “up front” or are yourpayments received as the player is compensated?Please list the names of the athletes, including UW former student-athletes, whom you have previouslyrepresented or currently represent who are currently under contract with a sports team/league and the name ofthe team representative with whom you negotiated these athletes’ contracts as an athlete agent during the fiveyears preceding the date of execution of this athlete agent disclosure form. Write “none” if you currently do notrepresent any athlete. If you represent athletes in more than one sport, please provide this information for eachsport. Use additional sheets if necessary:Player Name Team Client Phone Team RepresentativesUniversity of Washington Athletics Compliance

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? YesIf yes, please describe other occupation(s) or service(s) for which you are paid:NoPrevious employment within the past five years, (please attach an additional sheet foradditional space)Firm:Address:Firm:Position/Dates:City State ZipPosition/Dates:Address:City State ZipThree personal references (not related to the athlete agent)Name:Address:Name:Address:Name:Address:Phone:City State ZipPhone:City State ZipPhone:City State ZipUniversity of Washington Athletics Compliance

I certify that the above information 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 eligibilityremaining in his/her sport(s), I will notify in writing: (1) the student-athlete’s Head Coach; and (2)either the UW Director of Athletics or the UW Compliance Office. In addition, I have reviewed theNCAA rules related to agents and amateurism, the UW policies related to agents and the State ofWashington Athlete Agent Act (referred to collectively as “Rules, Policies and Statutes”). Iunderstand and agree to follow these Rules, Policies and Statutes in the future, and I represent that Ihave not engaged in any past behavior that has violated these Rules, Policies and Statutes or that hasjeopardized the eligibility of any student-athlete. I understand that the failure to comply with theseRules, Policies and Statutes may subject me to civil and/or criminal liability and may result in adecision prohibiting me from or any person(s) representing my firm firm/agency from contactingUW student-athletes with remaining eligibility.(Print Name)(Date)(Signature)Return Completed Form To:John MorrisUniversity of WashingtonDepartment of Intercollegiate AthleticsCompliance OfficeBox 354070Seattle, Washington 98195Fax: (206) 616-5813University of Washington Athletics Compliance