Application For Registration/renewal As An Athlete Agent - Secretary Of State - State Of Iowa Page 4

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15. 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
Explain:
16. 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
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
State Capitol, Room 105
Des Moines, IA 50319
Phone: (515) 281-8993 Fax: (515) 242-5952
Website:
Application for Registration/Renewal of Athlete Agent
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