Mississippi Athelete Agent Registration Form
In the case of wanting to register an athlete agent in the State of Mississippi, the following form has to be completed and submitted along with a $200 filing fee.
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Athlete Agent F0091 1
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11 F00 91
OFFICE OF THE MISSISSIPPI SECRETARY OF STATE
P O BOX 1020, JACKSON, MS 39215-1020
(601)359-1633
Applica tion for Registration or Renewal of Athlete Agent
A Certificate of Registration or a renewal of a registration of an Athlete Agent is valid for two (2)
years. Pursuant to Section 73- 42-9 of the Miss. Code Ann. ( 1972), as amended,
the undersigned hereby submits the following Application for Registration.
New Ap
plication Renewal Phone Number: ________________________
A . Name and address of applicant : ______________________________________________
Name: _______________________________________________________________________
Address: _____________________________________________________________________
City: __________________________________________ Sta
te:______ Zip :__ ____________
Em
ail
address: ________________________________________________________________
Website address: ______________________________________________________________
B Name an d address of the applicant’s business or employer, if applicabl e:
____________________________________________________________________________
C . Please state the business or occupation engaged in by the applicant for the five (5) years
preceding the date of submission of the application, i ncluding the name and address of such
business ( es):
____________________________________________________________________________
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D. Please provide a description of the applicant’s :
(a ) Formal training as an athlete agent:
____________________________________ ________________________________________
(b) Practical experience as an athlete agent:
____________________________________________________________________________
(c) Educational background relating to applicant’s activit ies as an athlete agent.
____________________________________________________________________________
E . Please provide as references the names and addresses of three (3) individuals not related to
the applicant:
Name: ______________________________________________________________________
Address: _____________________________________________________________________
City: ___________________________________________ S
tate:_______ Zip: ______________
Name: _
_____________________________________________________________________
Address: ____________________________________________________________________
City: __________________________________________State: _
_______ Zip:______________
Name: _
_____________________________________________________________________
Address: ____________________________________________________________________
City: __________________________________________State: _
_______ Zip:______________
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F. Please provide the n ame, sport, and last known team for each individual for whom the
applicant provided services as an athlete agent during the five (5) years preceding the date of
submission of the application.
Name and s port: ______________________________________________________________
Last known team: _____________________________________________________________
Name and sport : ______________________________________________________________
Last known team: _____________________________________________________________
Name and sport : ______________________________________________________________
Last known team: _____________________________________________________________
(If additional space is needed, please attach a list to this application.)
G. (a) If the Athlete A gent’s business is a corporation or LLC, please provide names and
addresses for all officers, directors, and any shareholder s or members of the corporation or LLC
with a 5% or greater interest:
Name: ______________________________________________________________________
Address: _____________________________________________________________________
City: ___________________________________________ S
tate:______ Zip: ______________
Name: _
_____________________________________________________________________
Address: ____________________________________________________________________
City: __________________________________________State: _
_______Zip:_____________
Name: _
_____________________________________________________________________
Address: ____________________________________________________________________
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City: __________________________________________State: _
_______Zip:_____________ _
(If
additional space is needed, please attach a list to this application.)
G. (b) If the athlete agent’s business is NOT a corporation or LLC , please produce nam es and
addresses of all partners, individuals, associates, officers:
Name: ______________________________________________________________________
Address: _____________________________________________________________________
City: ___________________________________________ S
tate:_______ Zip: _______________
Name: _
_____________________________________________________________________
Address: ____________________________________________________________________
City: __________________________________________ S
tate:________ Zip:_____________
Name: _
_____________________________________________________________________
Address: ____________________________________________________________________
City: __________________________________________State:__ _
_____ Zip:______________
(If
additional space is needed, please attach a list to this application.)
H . Has the applicant or any other person named pursuant to paragraph G above ever been
convicted of a crim e that, if comm itted in this state, would be a felony or other crime involving
moral turpitude? A crime (misdemeanor or felony) involving moral turpitude is one in which
deceit is an element of the crime.
Yes No
If yes , please state the name of that individual and identify the crime.
Name: ___________________________________________________________________
Identity of the crime : ________________________________________________________
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I. Has there ever been any administrative or judicial determination that applican t or any other
person named in paragraph G made a false or misleading, deceptiv e, or fraudulent
representation?
Yes No
If yes , explain:
____________________________________________________________________________
J. Has the conduct o f applicant or any other person named in paragraph G resulted in the
imposition of sanction, suspension, or declaration of ineligibility to participate in an
interscholastic or intercollegiate athletic event on a student athlete or on an educational
institution?
Yes No
If yes , explain:
____________________________________________________________________________
K. Have sanction s, suspension or disciplinary action ever been taken against the applicant or
any other person named pursuant to paragraph G arisi ng out of occupational or professional
conduct ?
Yes No
If yes , explain:
____________________________________________________________________________
L. Has there ever been a denial, refusal to renew , suspension, revocation, or cancellation of a
registration , licensure or certification of the applicant /registrant or any other person named in
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paragraph G a s an Athlete Agent by any state , or sanction, suspension, or other disciplinary
action imposed by any occupational or professional association?
Yes No
M. Is there any pending l itigation against the applicant in regard to the applicant’s capacity as an
Athlete Agent? Include administrative actions by state admi nistrative bodies, judicial civil
actions, and actions by professional and occupational organizations (i.e., NFLPA disciplinary
actions).
Yes No
If yes, please provide the name of the case, case number, jurisdiction, and brief explanation of
the fact s.
____________________________________________________________________________
N. Please list all of the states in which the applicant is currently licensed or registered as an
Athlete Agent and provide a copy of each state’s license, registration, or certification as
applicable.
____________________________________________________________________________
O. By signing this application, the applicant consents to submit to a criminal background check
before being issued a Certificate of Regi stration. A background check will be conducted at the
discretion of the Mississippi Secretary of State on an as needed basis to verify information
disclosed or withheld on this application. The applicant further agrees that the applicant will pay
any fees connected with said background check, if requested by the SOS, prior to the issuance
of the Certificate of Registration.
P . The applicant acknowledges that all registered Athlete Agents in the State of Mississippi
must notify the Secretary of State wi thin 30 days whenever the information contained in this
application changes in a material way, becomes inaccurate or incomplete in any respect. Such
events requiring notice shall include, but are not limited to, the following:
a) Change in address of the Athlete Agent’s principal place of business;
b) conviction of a felony or other crime involving moral turpitude by the Athlete Agent;
c) denial, suspension, refusal to renew, or revocation of a registration, license, or
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d) certification of the Athlete Agent as an Athlete Agent in any state; any sanction,
e) suspension, or other disciplinary action taken against the Athlete Agent arising out of
occupational or professional conduct.
The applicant understands and acknowledges that failure to accurately report the information
requested in this application may subject the applicant to criminal and civil penalties under
Section 73- 42-1 et seq. , of the Miss Code Ann.
I _______________________________ have read this A pplication for Registration or
(NAME)
Ren ewal of an Athlete Agent and the instructions and understand agree to all the terms and
conditions therein. I further swear or affirm that the information provided in this application is
true and correct as of the date submitted to the best of my knowledg e.
By: signature of
Applicant
Printed name: ___________________________________ Title:_________________________
Acknowledgement
State: ____________________
County: ___________________
I, hereby a notary public, do hereby certify that on the
________ day of ________________ 20____, who being by me first duly sworn, personally
appeared before me decla red that the statements herein contained are true and correct.
_________________________________________
Notary Seal
_________________________________________
Notary Public
My Commission Expires:
______________________________
M ake Check for $200.00 payable to the MISSISSIPPI SECRETARY OF STATE. Mail completed form with
payment to SECRETARY OF STATE, PO BOX 1020, JA CKSON, MS 39215-1020. For assistance contact a
custo
me
r service representative at (800) 256 -3494 or visit our website at
www.sos.ms.gov for forms and
instructions.
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