Subcommittee Member Self-Audit Checklist

Authorized Representative*

Email*

Trading Name

What is your government issued business registration ID*

How are you registered to do business in your jurisdiction*
CorporationPartnershipSole-proprietorNot a registered business

What jurisdiction/state/province/country you are registered to operate in? (if multiple, indicate primary)*

Are you licensed to perform your agency function in one or more jurisdictions*
Yes, as a sports agentYes, as a talent agentNoNo, registration is not applicable/available in my jurisdiction

Are you or any principles in your agency a (please check all that apply)
Licensed attorney at lawLicensed accountantLicensed investment adviserLicensed investment brokerLicensed stock trader

Is your agency bonded in one or more jurisdictions?
YesNo

List owner(s) of interests greater than 5% (please list name and percentage ownership)

List Directors, Officers, Partners, and/or Principles (please list name and title)

Has any person named above ever plead guilty or no contest to, or been convicted of a crime that would be a felony or a crime involving moral turpitude?*
YesNo

Has any person named above ever been subject to an administrative or judicial determination that he or she has made a false, misleading, deceptive, or fraudulent representation?*
YesNo

Has there been any instance in which the conduct of any person named above resulted in the imposition of a sanction, suspension, or declaration of ineligibility to participate in an interscholastic, intercollegiate, or professional athletic event on a student athlete or institution? *
YesNo

Has any sanction, suspension, or disciplinary action taken against any person named above arisen out of occupational or professional conduct?*
YesNo

Has any person named above been denied an application for, had a suspension or revocation of, refused to renew, or abandoned the registration or licensure as an athlete’s agent in any jurisdiction?*
YesNo

Has any person named above been a defendant or respondent in any civil proceeding, including a proceeding seeking an adjudication of incompetence, in the last 10 years?*
YesNo

Was any person named above adjudicated bankrupt, or was the owner of a business that was adjudicated bankrupt within the last 10 years?*
YesNo