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ATHLETE AGENT NOTICE OF
CONVICTION
Form #2510 Rev. 12/2011
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
This form may be used to notify the secretary of state of a conviction of a crime, regardless of where the
conviction occurred, if in Texas the crime would be an offense other than a Class C misdemeanor.
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 conviction. 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: OR
Registration
Number:
3. Principal
Business Address:
Street City State Zip
I have been convicted of a crime that in Texas would be an offense other than a Class C misdemeanor.
Copies of related documentation, including court order and sentence, and papers pertaining to release
from probation, if applicable, are attached. The following is a statement of (i) the nature, circumstances,
date, and location, and (ii) whether the matter is on appeal.
Execution
Date:
Signature of athlete agent
Printed or typed name
Form 2510
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