Application For Registration/renewal As An Athlete Agent - Iowa Secretary Of State Page 4
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1316. Has there been any sanction, suspension, or disciplinary action taken against the
applicant or any person named in question 11 arising out of occupational or professional
conduct:
Yes
No
If yes explain:
17. Has there been any denial of an application for, suspension or revocation of, or refusal
to renew, the registration or licensure of the applicant or any person named in question
11 as an athlete agent in any state:
Yes
No
If yes explain:
I understand that, as a registered Athlete Agent, I am bound by the laws of the State of
Iowa under Iowa Code chapter 9A. I certify that the information in the application is
complete and correct to the best of my knowledge.
Print Name of Applicant:
Signature of Applicant:
Date:
State of
County of
Signed and sworn (or affirmed) before me on:
Date)
X
(Signature of Notary Public)
My commission expires:
(Date)
Return completed form to:
Secretary of State
Athlete Agent Registration
Lucas Building,1st Floor
Des Moines, IA 50319
Phone: (515) 281-5204
Fax: (515) 242-5953
Website: sos.iowa.gov
Application for Registration/Renewal of Athlete Agent
Page 4 of 4
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