2014-15 PLAYER-AGENT REGISTRATION FORM

The completion of this form is required to be recognized as a registered agent of the University of Cincinnati Professional Sports Counseling Panel (UCPSCP).

NOTE: This form must be completed in its entirety.


General

Name:

Date of Birth:

Phone

Email Address:

Home Address

City:

State:

Zip Code:

If affiliated with a particular firm or agency as a player-agent, please indicate:

Name of Firm/Agency:

Business Address:

City:

State:

Zip Code:

Phone:

Cell Phone:

Fax:

Email:


Education

High School:

Name:

City:

State:

State:

College:

School Name:

City:

State:

Degree(s) and Year Graduated:

Graduate/Legal:

College or University:

City:

State:

Degree(s) Awarded and Year:

Admitted to Bar (If applicable):
Yes
No

State:

Date:


Experience

Number of years experience as a player-agent:

Sports in which you currently represent athletes and total number of athletes in each sport:


Other Qualifications

Are you currently registered with the Ohio Athletic Commission?
Yes
No

Sports in which you currently represent athletes and total number of athletes in each sport:

Occupational or professional licenses and date obtained:

Are you currently certified by the NFLPA?
Yes
No

Permanent Or Provisional
Permanent
Provisional

Are you currently certified by the NBPA?
Yes
No

Permanent Or Provisional
Permanent
Provisional

Are you currently certified by the MLBPA?
Yes
No

Permanent Or Provisional
Permanent
Provisional


Professional Services

General Services performed for client-athletes (check those that apply and indicate fee charged):

Playing contract negotiations:
Yes
No

Hourly fee or percentage:

Endorsement contract negotiations:
Yes
No

Hourly fee or percentage:

Legal Assistance:

Tax Consulting:

Financial Planning:

Money Management:

For the services you perform for client-athletes, list the names and addresses of individuals, firms, or agencies who assist you in providing these services. Use additional sheets if necessary:

In receiving compensation for contract negotiation services, do you receive payment "up front" or are your payments received as the player is compensated?

Please list the names of any current University of Cincinnati student-athletes that you wish to contact during the 2014-15 academic year:

Please list the names of any athletes, including UC athletes, that you previously or currently represent and, in team sports, the team/league to which each athlete is currently under contract and the name of the team representative with whom you negotiated this contract. Write "none" if you currently do not represent any athlete. If you represent athletes in more than one sport, please provide this information for at least five clients in each sport. Use additional sheets if necessary (Please list: Player Name, Team, Client's Phone, Team Rep):

Do you earn income from work performed in some capacity other than as a player agent?

If yes, please describe the other occupation or services for which you are paid.


Previous Employment

Previous Employment Information


References (3)

Reference Information

I certify that the above information is true, correct, and complete to the best of my knowledge. Further, I certify that I will notify Maggie McKinley or Brandon Wright before the first contact with a student-athlete who has eligibility remaining in any sport and is enrolled at the University of Cincinnati.
Yes
No

Furthermore, I have reviewed the NCAA rules and regulations that accompany this form and have not engaged in any activity prior to a student-athlete's agreement to be represented that would jeopardize the student-athlete's eligibility. I also understand that failure to comply with the terms of this certification and the applicable NCAA legislation may result in the initiation of legal proceedings by the University of Cincinnati against me and the assessment of civil and/or criminal penalties to me.
Yes
No