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NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE (North Carolina Secretary of State)

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tT
1
Revised March 2011
Elaine F. Marshall
Secretary of State
NORTH CAROLINA DEPARTMENT OF THE
SECRETARY OF STATE
P.O. Box 29622
Raleigh, NC 27626-0622
https://www.sosnc.gov
919-814-5400
APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT
N.C.G.S. §§ 78C-89(a)(1)-(12) – APPLICATION FORM
Date:
*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*
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
CHECK ONE: INITIAL APPLICATION ? RENEWAL APPLICATION ?
Telephone:
Email:
2
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
3
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.):
4
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 BUSINESS PHONE#
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.
5
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 of Representation
______________________________________________________________________________
___ Name Sport Last Known Team Dates of Representation
6
SECTION 3. BUSINESS MEMBERSHIP
10) PLEASE ANSWER EITHER QUESTION 10
A
OR QUESTION 10
B
DEPENDING ON WHETHER OR
NOT YOUR BUSINESS OR EMPLOYER IS A CORPORATION.
A
Check
When
Compl-
eted.
B
?
Check
When
Compl-
eted.
NON-CORPORATIONS
INCORPORATED BUSINESS ENTITIES
With respect to the applicant’s business or employer,
if it is not a corporation
, then please give the
NAMES and ADDRESSES of ALL: 1) PARTNERS; 2) MEMBERS; 3) OFFICERS; 4)
MANAGERS; 5) ASSOCIATES; and 6) PROFIT-SHARERS associated with that business or
employer. (Use Space Below As Needed.)
With respect to a
corporation
employing the applicant, please give the
NAMES
and
ADDRESSES
of
ALL: 1) OFFICERS; 2) DIRECTORS; and 3) ANY SHAREHOLDER OF THE CORPORATION
HAVING AN INTEREST OF FIVE PERCENT (5%) OR GREATER associated with that
corporation. (Use Space Below As Needed.)
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
7
DIRECTIONS. Make copies of this page as needed to provide the requested information.
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
Name
Position
Address
8
SECTION 4. APPLICANT AND BUSINESS MEMBERSHIP CONDUCT
PLEASE REVIEW QUESTIONS 11 THROUGH 15 CAREFULLY BEFORE ANSWERING. PLEASE ANSWER THESE Q
UESTIONS
IN REGARD TO THE APPLICANT AND EVERY INDIVIDUAL LISTED IN RESPONSE TO QUESTION 10 A OR 10 B AS
ANSWERED ABOVE.
11) CRIMINAL CONVICTIONS
Please state whether or not the applicant or any person named in response to
question A or B above has been c
onvicted of a crime involving moral turpitude
or a felony and identify the crime. (Attach additional sheets as needed.)
?
NOT APPLICABLE
Check if the applicant or listed
business membership has not been
convicted of a crime.
1)
Name Crime Date and Place of Conviction
2) Name Crime Date and Place of Conviction
3) Name Crime Date and Place of Conviction
12) MAKING FALSE, MISLEADING, DECEPTIVE OR FRAUDULENT MISREPRESENTATIONS
Please state whether or not there has been any administrative or judicial determination that the applicant or
any person named in response to question 10 A or 10 B above has made a false, misleading, deceptive, or
fraudulent misrepresentation. Explain each such determination, if any, in the space below. (Attach additional
sheets as needed.)
?
NOT APPLICABLE
Check if there has been no
determination that the applicant or
listed business membership has made
a false, misleading, deceptive or
fraudulent misrepresentation.
9
13) CONDUCT NEGATIVELY IMPACTING UPON EITHER STUDENT ATHLETES OR
EDUCATIONAL INSTITUTIONS
Please state whether or not there are any instances in which conduct of the applicant or any person named in
response to question 10 A or 10 B above resulted in the imposition of a sanction, suspension, or declaration of
ineligibility to participate in an interscholastic or intercollegiate athletic event on a student athlete or
educational institution. Describe each such instance, if any. Include a separate entry for each person named
in response to this section. (Attach additional sheets as needed.)
?
NOT APPLICABLE
Check if there are no instances in
which conduct of the applicant or
listed business membership has
resulted in the imposition of a
penalty against
a student-
athlete or
educational institution
14) OCCUPATIONAL OR PROFESSIONAL MISCONDUCT
Please state whether or not any sanction, suspension, or disciplinary action has been taken against the
applicant or any person named in response to question 10 A or 10 B above arising out of occupational or
professional misconduct. Describe each such action, if any. Include a separate entry for each person named
in response to this question. (Attach additional sheets as needed.)
?
NOT APPLICABLE
Check if there has been no sanction,
suspension, or disciplinary action
taken against the applicant or listed
business membership arising out of
occupational or professional
misconduct.
10
15) REGISTRATION OR LICENSURE AS AN ATHLETE AGENT IN ANY STATE
Please state whether or not there has been in any state regarding the applicant or any person named in
response to question 10 A or 10 B above: 1) any denial of an application for registration or licensure as an
athlete agent; or 2) suspension or revocation of registration or licensure as an athlete agent; or 3) refusal to
renew the registration or licensure as an athlete agent. Describe each such instance. Include a separate entry
for each person named in response to this section. (Attach additional sheets as needed.)
?
NOT APPLICABLE
Check if there has been no 1) denial of an
application for registration or licensure as
an athlete agent; or 2) suspension or
revocation of registration or licensure as
an athlete agent; or 3) refusal to r
enew the
registration or licensure as an athlete
agent.
OATH/AFFIRMATION
I do hereby swear (affirm) that the information furnished in this form and ____ attached
pages is true and correct to the best of my knowledge under penalty of perjury. I
understand that giving false information in this form constitutes cause for denial of my
application or revocation of my Registration and could subject me to criminal prosecution.
Signature of Applicant: ____________________________________________________
Date: ___________________________________________
State of )
County of )
Sworn and subscribed to me this ______ day of ____________________,____________
Month Year
________________________________________________
Notary Public Signature
My Commission Expires: _______________________________
Notary Seal
11
Please Check One of the Following Fees Submitted with this Application. (Make Checks Payable to:
“NC Department of the Secretary of State”)
END OF APPLICATION
NOTICE OF ALTERNATIVE METHOD OF APPLICATION
In lieu of submitting this application, an applicant seeking registration or renewal of registration as an athlete
agent in North Carolina may submit:
1) A copy of another state’s application for licensure or registration or renewal of licensure or
registration; and
2) A copy of the certificate or license of registration issued by the other state.
In addition, the following conditions must be met:
A) The other state’s application must have been submitted to the other state within six months
immediately preceding its submission in North Carolina; and
B) The applicant certifies that the information contained in the other state’s application is
current (may use Oath/Affirmation above); and
C)
The other state’s application as it was submitted contains information substantially similar to
that required by this application; and
D) The applicant signed the other state’s application under penalty of perjury as part of his or
her application to the other state.
REQUEST FOR TEMPORARY REGISTRATION
The Secretary of State may issue a temporary certificate of registration while an application for registration
or renewal is pending. An applicant must request a temporary registration in writing with his or her
submission of a completed application for registration.
SECTION 6. FEES
APPLICATION FEES ARE NONREFUNDABLE
A. INITIAL APPLICATION FOR REGISTRATION AS AN ATHLETE AGENT
NC APPLICATION FOR REGISTRATION AS AN
ATHLETE AGENT
$200.00
OTHER STATE APPLICATION FOR REGISTRATION
AS AN ATHLETE AGENT
$200.00
B. RENEWAL OF REGISTRATION AS AN ATHLETE AGENT
NC APPLICATION FOR
RENEWAL OF
REGISTRATION
OTHER STATE APPLICATION FOR RENEWAL OF
REGISTRATION
$200.00
$200.00
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NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE (North Carolina Secretary of State)

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Completed 30 July 2020

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