Regulations on Working With Intermediaries
24 March 2015 9| Page
SCHEDULE A – INTERMEDIARY DECLARATION FOR NATURAL PERSONS
Intermediary Details (Natural Persons):
First name(s):
Surname(s):
Date of birth: DD / MM / YYYY
Nationality /
nationalities:
Phone:
Email:
Full permanent
address:
Address: City:
State / Territory: Postcode:
Privacy notice:
The personal information that Football Federation Australia Limited (FFA) collects from you on this declaration is collected
for the purposes of administering FFA’s Regulations on Working with Intermediaries, assisting with your enquiries and for
other purposes set out in FFA’s privacy policy. FFA’s privacy policy (available at www.ffa.com.au), explains how FFA
collects, uses and discloses personal information and how you may access and correct the personal information that FFA
holds about you. It also tells you how you may contact FFA to complain about a breach of the Privacy Act 1988 (Cth), and
how FFA will deal with such a complaint. If you have any queries or would like further information, please contact FFA’s
Privacy Officer via email privacy@ffa.com.au.
Declaration:
I, __________________________________________________________________
(First name(s), surnames(s) of intermediary)
DO SOLEMNLY AND SINCERELY DECLARE THAT:
I pledge to respect and comply with any mandatory provisions of applicable national and international laws,
including in particular those relating to job placement when carrying out my activities as an
intermediary. In addition, I agree to be bound by the statutes and regulations of Football Federation
Australia Limited (FFA), associations and confederations, as well as by the Statutes and regulations
of FIFA in the context of carrying out my activities as an intermediary.
I declare that I am currently not holding a position of official, as defined in point 11 of the Definitions section of
the FIFA Statutes, nor will I hold such a position in the foreseeable future.
I declare that I have an impeccable reputation and in particular confirm that no criminal sentence has ever
been imposed upon me for a financial or violent crime.
I declare that I have no contractual relationship with FFA, leagues, associations, confederations or FIFA that
could lead to a potential conflict of interest. In the case of uncertainty, any relevant contract shall be
disclosed. I also acknowledge that I am precluded from implying, directly or indirectly, that such a
Regulations on Working With Intermediaries
24 March 2015 10| Page
contractual relationship with FFA, leagues, associations, confederations or FIFA exists in connection
with my activities as an intermediary.
I declare, pursuant to clause 6.6 of FFA’s Regulations on Working with Intermediaries, that I shall not accept
any payment to be made by one club to another club in connection with a transfer, such as transfer
compensation, training compensation or solidarity contributions.
I declare, pursuant to clauses 6.1 and 6.2 of FFA’s Regulations on Working with Intermediaries, that I shall not
accept any payment from any party if the player concerned is a minor, as defined in point 11 of the
Definitions section of FIFA’s Regulations on the Status and Transfer of Players.
I declare that I shall not take part in, either directly or indirectly, or otherwise be associated with, betting,
gambling, lotteries and similar events or transactions connected with football matches. I acknowledge
that I am forbidden from having stakes, either actively or passively, in companies, concerns,
organisations, etc. that promote, broker, arrange or conduct such events or transactions.
I consent, pursuant to clause 5.2 of FFA’s Regulations on Working with Intermediaries, to the association
obtaining full details of any payment of whatsoever nature made to me by a club or a player for my
services as an intermediary.
I consent, pursuant to clause 5.3 of FFA’s Regulations on Working with Intermediaries, to the leagues,
associations, confederations and/or FIFA obtaining, if necessary, for the purpose of their
investigations, all contracts, agreements and records in connection with my activities as an
intermediary. Equally, I consent to the aforementioned bodies also obtaining any other relevant
documentation from any other party advising, facilitating or taking any active part in the negotiations
for which I am responsible for the purpose of their investigations.
I consent, pursuant to clause 5.1 of FFA’s Regulations on Working with Intermediaries, to FFA holding,
processing and publishing any data for the purpose of their publication.
I consent, pursuant to clause 8.4 of FFA’s Regulations on Working with Intermediaries, to FFA publishing
details of any disciplinary sanctions taken against me and informing FIFA accordingly.
I am fully aware and agree that this declaration shall be made available to the members of the competent
bodies of FFA.
I consent to the collection, use and disclosure of my personal information as described in this declaration and
for the purposes set out in FFA’s privacy policy (available at www.ffa.com.au), including administering
FFA’s Regulations on Working with Intermediaries.
I make this solemn declaration in good faith, the truth of which is based on the information and materials
currently available to me, and agree that FFA is entitled to undertake such checks as may be necessary to
verify the information contained in this declaration. I also acknowledge that, having submitted this declaration,
in the event that any of the above-mentioned information changes, I must notify FFA immediately.
______________________________ ___________________________
(Print Name) (Signature)
______________________________
(Place and date)
______________________________ ___________________________
(Witness Name) (Witness Signature)
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