Athlete-Agent Questionnaire
The completion of this form does not satisfy the Wisconsin statute requiring athlete agents to file
with the Department of Regulation and Licensing.
Contact Information:
State of Wisconsin Department of Regulation and Licensing
1400 East Washington Avenue, 1Room 173
PO Box 8935
Madison, WI 53708-8935
(608) 266-2112
http://drl.wi.gov
[email protected]
Statement of Understanding
The following information is provided as a service to aid the University of Wisconsin-Madison’s Office of Athletic
Compliance in better understanding the type and kinds of services and expertise offered by the respondent in
preparation for future professional sports representation. It is acknowledged by all parties to this communication that
the responses are intended to assist student-athletes in learning more about the particular firm and its
agents/representatives. Part of this process is accomplished by reference to the information provided below – in
other instances, by personal interview or meeting.
Cognizant of the need to provide accurate and reliable information, it is understood by those reviewing this material
that the answers provided can be relied upon for their veracity and accuracy. If additional information is required to
respond to a specific question, please attach whatever documentation is appropriate.
In submitting this form, I voluntarily agree to comply with and be bound by any applicable state law. I further
understand that by making any false or misleading statement of any nature in answering a question on this form, that
the firm or individual may be identified to all institutional representatives (including student-athletes, parents/legal
guardians) and any other collegiate institution that may deem such lack of disclosure appropriate in counseling
student-athletes regarding future professional sport opportunities.
_____________________________________________________________________________________________
Agent’s Signature
Date
1
University of Wisconsin-Madison
Athlete-Agent Questionnaire
Section I: General Information
Full Name:
Have you ever been known by any other name or surname? ___Yes ___No
Name of Your Organization:
Your Title:
Organization’s Address:
City/State/Zip Code:
Work Phone:
Fax:
Email:
Section II: Agent
I am a registered athlete agent, in good standing with the State of Wisconsin.
Yes
No
I am a certified agent, in good standing as of the date of the completion of this form with the
following: (check all which apply)
Major League Baseball Players Association
National Basketball Players Association
National Football League Players Association
National Hockey League
Other, please list
2
Section III: Education
Law or Graduate School Attended:
________________________________________________________________________
(School)
(City, State)
________________________________________________________________________
(Degree)
(Date Awarded)
________________________________________________________________________
(School)
(City, State)
________________________________________________________________________
(Degree)
(Date Awarded)
College or Universities Attended:
________________________________________________________________________
(School)
(City, State)
________________________________________________________________________
(Degree)
(Date Awarded)
________________________________________________________________________
(School)
(City, State)
________________________________________________________________________
(Degree)
(Date Awarded)
High School Attended:
________________________________________________________________________
(School)
(City, State)
________________________________________________________________________
(Degree)
(Date Awarded)
3
Section IV: Lawyers/Law Graduates
(If you are not a lawyer or law graduate, please proceed to Section V)
A. Please list the jurisdictions in which you have been admitted to the Bar and the
corresponding dates of admission:
Jurisdiction
Date of Admission
Status
B. Do you have any application for Bar admission currently pending?
If yes, please state where you have applied and the status of the application:
C. If you have ever been disbarred, suspended, reprimanded, censured or otherwise
disciplined or disqualified as an attorney, a member of any other profession, or a
public office holder, please provide the following information:
Action
Date of Occurrence
Authority Imposing
Authority’s Address
D. If any charges or complaints are currently pending against you regarding your conduct
as an attorney, a member of any profession, or a public office holder, please provide
the following information:
Charge/Complaint Pending
Authority Considering
Authority’s Address
E. Has your right to practice before any governmental office, bureau, agency,
commission, etc., ever been disqualified, suspended, withdrawn, denied, or
terminated?
__________YES
__________NO
If Yes, please explain:
4
Section V: Professional Background
(All Applicants)
A. List your employment history for the last (10) years.
B. Please list below the names of all athletes and coaches you are now representing or
have represented in the past (5) years in individual contract negotiations with
professional sports teams indicating the dates of representation and the team(s)
involved. If the total of your clients for this time period exceeds ten, list only your
present and former clients in any sport in which you are seeking to represent a
University of Wisconsin student-athlete primarily in the sports of football, basketball
and ice hockey. If you prefer, you may attach a list with this information.
Athlete’s Name & Address
Dates
Sport(s)
5
Teams
C. Please identify your areas of expertise in reference to professional sports/agent
representation:
D. List any occupational or professional licenses or other similar credentials you have
obtained other than college or graduate degrees, including the dates they were
obtained:
E. If you have ever been denied an occupational or professional license, franchise or
other similar credentials for which you applied, please explain:
F. If you have ever been suspended, reprimanded, censured, or otherwise disciplined
or disqualified as a member of any profession, or as a public office holder, please
indicate below:
Action
Date of Occurrence
Authority Imposing
6
Authority’s Address
G. Has your right to engage in any profession or occupation ever been disqualified,
suspended, withdrawn or terminated?
YES
NO
If YES, please explain:
H. If you have ever been disciplined or cited for a violation of a state statute regulating
athlete agents, please complete the following.
Charge/Complaint
Date of Alleged Violation
7
Status
Authority Imposing
Section VI: Compliance Background
NCAA
If you have ever been involved or accused of participating in any action alleged to have been in
violation of the rules of the NCAA, any conference, any university or college, any players
association, and/or sports club, league, federation or team, please complete the below:
Date of Alleged Violation
Allegation
Result/Status
Authority Imposing
Criminal Charges
If you have ever been convicted of or pled guilty to a criminal charge, other than minor traffic
violations, please complete the below:
Date of Conviction
Offense
Criminal Authority Involved
Punishment Assessed
Other Compliance Issues
Have you ever been a defendant in any civil proceedings, including bankruptcy, in which allegations of
fraud misrepresentation, embezzlement, misappropriation of funds, conversion, breach of fiduciary duty,
forgery, or legal malpractice were made against you?
YES
NO
Has any court ever adjudicated you insane or legally incompetent?
YES
NO
Have you ever been suspended or expelled from any college, university, law school or graduate school?
YES
NO
Are there any unsatisfactory judgments of continuing effect against you?
YES
Have you been declared bankrupt or been an owner or part owner in a business which declared
bankruptcy?
YES
NO
IF YOU ANSWERED YES TO ANY OF THESE QUESTIONS,
PLEASE ATTACH A WRITTEN EXPLANATION FOR EACH.
8
NO
Section VII: Services
A. Please indicate the services you/your organization offer to athletes
(check all that apply):
Contract Negotiation
Financial Planning
Appearances/Endorsements
Tax Planning
Estate Planning
Insurance Planning/Coverage
Investment Counseling
Grievance/Arbitration
Other Services
B. Please Indicate whether your organization does the following:
1. Do you offer separate contracts for each service?
2. Do you handle athletes’ funds?
If yes, are you bonded?
3. Are you currently registered under the Investment Advisor’s Act?
4. Do you receive a fee from any individual(s)/firm(s) for referral?
If yes, what is the basis of any fee?
5. If you assist players with securing the services you do not provide, please
indicate below the individual(s)/firm(s) to which you customarily refer players
for each service:
Services
Individual Firm
Address
Phone
6. How and when are you paid?
7. Who actually negotiates contracts on behalf of the athletes?
8. What is the duration of the agreement between you and the athlete?
9. What happens if you or the athlete wants to terminate the agreement?
10. What happens to the agreement if the athlete is waived from a team?
9
Section VIII: References
Please provide a list of three character references who are not related to you, not engaged in business with you, have known you
for at least three years, and can attest to your character. For each, provide the following information:
Name
Address
Phone
Relationship
Please provide a list of at least two entities which can attest to your financial credit.
Organization
Contact
Address
10
Phone
Acknowledgement
I certify that the information provided on this questionnaire is complete and correct. I have
read the forgoing questions and have personally answered the same fully and honestly. The
answers to said questions are true and accurate to the best of my knowledge.
(Applicant’s Signature)
(Date)
Please return questionnaire to:
Katie Smith
Associate Athletic Director for Compliance
University of Wisconsin-Madison
1440 Monroe Street
Madison, WI 53711
(608) 265-5071
[email protected]
11