Free Cl - Kansas

Our fees increased September 1, 2003. Please review the instruction box on the form for the new fee. Contact Information
Kansas Secretary of State Ron Thornburgh Memorial Hall, 1st Floor 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 [email protected] www.kssos.org Please check the following: New registration ______

KANSAS SECRETARY OF STATE

Athlete Agent Registration
All information must be completed or this document will not be accepted for filing.

AA
81

Renewal registration ______

Name of applicant (must be an individual): ___________________________________________________________ Applicant's principal business address:

Do not write in this space

____________________________________________ ___________________________ _______________ ______________
Street address City State Zip

Telephone number: _______________________________ Name of Applicant's business or employer (if applicable): ___________________________________________________________ Type of entity (Check one) ______ Individual ______ Corporation ______ Association ______ Partnership ______ LLC ______ Other

Instructions
Filing Fee: $515.00 1. 2. 3. 4. 5. List the business(es) or occupation(s) engaged in for the five years immediately preceding the application or renewal request date (Appendix A). List all formal training, practical experience and educational background relating to applicant's professional activities as an athlete agent (Appendix B). Names and addresses of three (3) individuals not related to the applicant willing to serve as references (Appendix C). List the name, sport and last known team for each individual for whom the applicant acted as an athlete agent during the five years immediately preceding the date of this application or renewal request (Appendix D). List names and addresses of all persons who are partners, members, officers, managers, associates or profit-sharers with respect to the athlete agent's business or employer if it is not a corporation. If the applicant is employed as an athlete agent by a corporation, list the names and addresses of all officers and directors, and any shareholder of the corporation having a five percent (5%) or greater interest (Appendix E). Please answer all of the questions listed in Appendix F for the applicant and each person identified in #5 above, include appropriate explanations when indicated. Sign and date the application or renewal request under penalty of perjury. An individual holding a certificate of registration or licensure as an athlete agent in another state may submit a copy of that application and certificate in lieu of completing this application, provided that: 1) the other state's application was submitted to that state within six (6) months immediately preceding the date of the application to this state; 2) the applicant certifies that the information in the other state's application is current; 3) the information in the other state's application contains information substantially similar to or more comprehensive than that required in an application submitted to this state; and 4) the other state's application was signed under penalty of perjury (Appendix G).
1/8

2 a

6. 7. 8.

3 a ( o

s

Notice: There is a $25 service fee for all returned checks.

2 f

Appendix A
Use additional sheets as necessary
List the business(es) or occupation(s) the applicant engaged in for the five years immediately preceding the date of this application or renewal request. Business or occupation: _____________________________________________________________ Address: ______________________________ ____________________ ________ ____________
Street address City State Zip

Dates: ___________________________________________________________________________ Duties: __________________________________________________________________________ __________________________________________________________________________ Name of supervisor: ________________________________________________________________

Business or occupation: _____________________________________________________________ Address: ______________________________ ____________________ ________ ____________
Street address City State Zip

Dates: __________________________________________________________________________ Duties: __________________________________________________________________________ __________________________________________________________________________ Name of supervisor: ________________________________________________________________

Business or occupation: _____________________________________________________________ Address: ______________________________ ____________________ ________ ____________
Street address City State Zip

Dates: ___________________________________________________________________________ Duties: _________________________________________________________________________ _________________________________________________________________________ Name of supervisor: ________________________________________________________________

2/8

Appendix B
List all of the applicant's formal training, practical experience and educational background relating to professional activities as an athlete agent. Formal training: Description/dates/location/contact (include telephone number): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Practical experience: Description/dates/location/contact (include telephone number):

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Educational background: School(s)/dates/degree or certification: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

3/8

Appendix C
Names and addresses of three (3) individuals not related to the applicant willing to serve as references. Name: __________________________________________________________________________ Address: ______________________________ ______________________ _________ _________
Streeet address City State Zip

Name: _______________________________________________________________________ Address: ______________________________ ______________________ _________ _________
Streeet address City State Zip

Name: _______________________________________________________________________ Address: ______________________________ ______________________ _________ _________
Streeet address City State Zip

4/8

Appendix D
Use additional sheets as necessary List the name, sport and last known team for each individual for whom the applicant acted as an athlete agent during the five years immediately preceding the date of this application or renewal request. Name: ___________________________________________________________________________ Sport: _____________________________ Last known team: _______________________________

Name: ___________________________________________________________________________ Sport: ______________________________ Last known team: ______________________________

Name: ___________________________________________________________________________ Sport: ______________________________ Last known team: ______________________________

Name: ___________________________________________________________________________ Sport: ______________________________ Last known team: ______________________________

Name: ___________________________________________________________________________ Sport: ______________________________ Last known team: ______________________________

Name: ___________________________________________________________________________ Sport: ______________________________ Last known team: ______________________________

Name: ___________________________________________________________________________ Sport: ______________________________ Last known team: ______________________________

5/8

Appendix E
Use additional sheets as necessary List names and addresses of all persons who are partners, members, officers, managers, associates or profit-sharers with respect to the athlete agent's business if it is not a corporation. If the applicant is employed as an athlete agent by a corporation, list the names and addresses of all officers and directors, and any shareholder of the corporation having a five percent (5%) or greater interest. Name: ___________________________________________________________________________ Address: _________________________________ ____________________ _______ __________
Street address City State Zip

Title or position: ______________________________ Ownership interest (if any): ________________

Name: ___________________________________________________________________________ Address: _________________________________ ____________________ _______ __________
Street address City State Zip

Title or position: ______________________________ Ownership interest (if any): ________________

Name: ___________________________________________________________________________ Address: _________________________________ ____________________ _______ __________
Street address City State Zip

Title or position: ______________________________ Ownership interest (if any): ________________

Name: ___________________________________________________________________________ Address: _________________________________ ____________________ _______ __________
Street address City State Zip

Title or position: ______________________________ Ownership interest (if any): _______________

Name: ___________________________________________________________________________ Address: _________________________________ ____________________ _______ __________
Street address City State Zip

Title or position: ______________________________ Ownership interest (if any): ________________

6/8

Appendix F
Use additional sheets as necessary Please answer each of the following questions with regard to the applicant and each person identified in Appendix E. If any question is answered yes, please provide a detailed explanation on a separate sheet. 1. Has the conduct of the applicant or any person identified in Appendix E resulted in the imposition of a sanction, suspension or declaration of ineligibility of a student-athlete or educational institution to participate in an interscholastic or intercollegiate athletic event (Yes or No)? _____ 2. Has the applicant or any person identified in Appendix E ever been sanctioned, suspended or disciplined as a result of occupational or professional conduct (Yes or No)? _____ 3. Has the applicant or any person identified in Appendix E ever had an athlete agent application or renewal request denied (Yes or No)? _____ 4. Has the applicant or any person identified in Appendix E ever had an athlete agent registration or license suspended or revoked (Yes or No)? _____ 5. Has the applicant or any person identified in Appendix E ever been convicted of a felony, or of a misdemeanor involving moral turpitude (Yes or No)? _____ 6. Has the applicant or any person identified in Appendix E ever been administratively or judicially determined to have made a false, misleading, deceptive or fraudulent representation (Yes or No)? _____

I declare under penalty of perjury under the laws of the State of Kansas that the foregoing application is true and correct. Executed this ______ day of ________________ , 20 _____ .
Month Year

_______________________________________________________
Applicant's Signature

7/8

Appendix G
(Only for use in lieu of application under circumstances of reciprocity)

CERTIFICATE OF RECIPROCITY
I, the undersigned applicant for athlete agent registration in the State of Kansas, declare under penalty of perjury pursuant to the laws of the State of Kansas that the attached copy of the application of, and certificate of registration or licensure issued by, the State of __________________ was submitted to said state within six (6) months of the date of this Certificate of Reciprocity; that the information therein is current; that the information therein is similar to or more comprehensive than that required by the State of Kansas for athlete agent registration; and that said state's application was signed under penalty of perjury. Executed this ______ day of ________________ , 20 _____ .
Month Year

_______________________________________________________
Applicant's Signature

Rev. 08/11/03 amc

L. 2003, Ch. 109 8/8