Form DBPR AA-4101 "Application for Licensure as an Athlete Agent" - Florida

Form DBPR AA-4101 or the "Application For Licensure As An Athlete Agent" is a form issued by the Florida Department of Business & Professional Regulation.

The form was last revised in October 1, 2014 and is available for digital filing. Download an up-to-date Form DBPR AA-4101 in PDF-format down below or look it up on the Florida Department of Business & Professional Regulation Forms website.

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Download Form DBPR AA-4101 "Application for Licensure as an Athlete Agent" - Florida

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State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Application for Licensure as an Athlete Agent
Form # DBPR AA-4101
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Fee of $880. Make check payable to the Florida Department of Business
and Professional Regulation.
 Completed form DBPR AA-4101 - Application for Licensure as an Athlete
Application for
Agent.
Licensure as an
 Electronic fingerprints.
Athlete Agent
 Supporting legal documentation (if applicable). See Section 2(b) of
Instructions.
 Fee of $505. Make check payable to the Florida Department of Business
and Professional Regulation.
 Electronic fingerprints.
Reinstatement from
 Provide an explanation of illness or economic hardship that prevented
Null and Void
renewal and any documents you wish to provide to support your claim of
hardship.
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Athlete Agent License
a. Applicant must be at least 18 years of age.
b. Applicant must submit electronic fingerprints.
i.
Electronic fingerprinting is available at various convenient sites throughout the state. See
http://www.myfloridalicense.com/dbpr/servop/testing/documents/finger_faq.pdf
for more
information.
c.
If you are an applicant who holds a certificate, license or registration as an Athlete Agent in
another state you may submit a copy of the application and certificate in lieu of this
application if the application to the other state was submitted in the other state within six
months preceding the submission of the application in Florida and the applicant certifies that
the information contained in the application is current; contains information substantially
similar to or more comprehensive than that required in an application submitted in Florida;
and was signed by the applicant under penalty and perjury. You must also submit a fee in the
amount of $880 and electronic fingerprints.
2. Application Instructions (by section)
a. Section I-Transaction Type
i.
Check application type.
ii.
If you are applying for reinstatement from null and void, provide a detailed explanation for
your illness or undue hardship that prevented renewal. Provide your previous license
number.
b. Section II- Applicant Information
i.
Fill out each section completely. A Social Security number is required in order to apply
for any individual license within the Department of Business and Professional Regulation.
DBPR AA 4101- Application for Licensure as an Athlete Agent
Incorporated by Rule: 61-35.004
Effective: 2014 October
1 of 7
State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Application for Licensure as an Athlete Agent
Form # DBPR AA-4101
APPLICATION CHECKLIST – IMPORTANT – Submit all items on the checklist below with your
application to ensure faster processing.
APPLICATION
APPLICATION REQUIREMENTS
 Fee of $880. Make check payable to the Florida Department of Business
and Professional Regulation.
 Completed form DBPR AA-4101 - Application for Licensure as an Athlete
Application for
Agent.
Licensure as an
 Electronic fingerprints.
Athlete Agent
 Supporting legal documentation (if applicable). See Section 2(b) of
Instructions.
 Fee of $505. Make check payable to the Florida Department of Business
and Professional Regulation.
 Electronic fingerprints.
Reinstatement from
 Provide an explanation of illness or economic hardship that prevented
Null and Void
renewal and any documents you wish to provide to support your claim of
hardship.
Please mail your completed application, documentation and required fee(s) to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. General Requirements for Athlete Agent License
a. Applicant must be at least 18 years of age.
b. Applicant must submit electronic fingerprints.
i.
Electronic fingerprinting is available at various convenient sites throughout the state. See
http://www.myfloridalicense.com/dbpr/servop/testing/documents/finger_faq.pdf
for more
information.
c.
If you are an applicant who holds a certificate, license or registration as an Athlete Agent in
another state you may submit a copy of the application and certificate in lieu of this
application if the application to the other state was submitted in the other state within six
months preceding the submission of the application in Florida and the applicant certifies that
the information contained in the application is current; contains information substantially
similar to or more comprehensive than that required in an application submitted in Florida;
and was signed by the applicant under penalty and perjury. You must also submit a fee in the
amount of $880 and electronic fingerprints.
2. Application Instructions (by section)
a. Section I-Transaction Type
i.
Check application type.
ii.
If you are applying for reinstatement from null and void, provide a detailed explanation for
your illness or undue hardship that prevented renewal. Provide your previous license
number.
b. Section II- Applicant Information
i.
Fill out each section completely. A Social Security number is required in order to apply
for any individual license within the Department of Business and Professional Regulation.
DBPR AA 4101- Application for Licensure as an Athlete Agent
Incorporated by Rule: 61-35.004
Effective: 2014 October
2 of 7
ii.
In the Full Legal Name section provide your full legal name as it appears on your Social
Security card. Do not use any nicknames or initials. Please list any aliases or prior names
in the Prior Name information section.
iii.
Provide your mailing address. This will be used for sending correspondence regarding
your application and license.
iv.
Contact information is often used to quickly resolve questions with applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
v.
Applicants are required to provide at least one physical address – i.e., not a P.O. Box. If
the mailing address is not also your physical address, please provide a physical address.
vi.
Applicant’s addresses are used only for Department purposes and will not be printed on
the license.
vii.
Additional contact information is optional and will be used when the applicant cannot be
reached using their primary contact information.
viii.
Applicants must provide information on current or prior licenses held in Florida or any
other state, territory, or jurisdiction of the United States or in any foreign national
jurisdiction.
ix.
Applicants must provide information on any prior names or aliases used by applicant. If
the name on supporting documentation does not match the applicant’s legal name, the
alias used in the supporting documentation must be provided in this section. Failure to do
so will result in a deficient application.
c. Section III (a), (b), and (c)- Background Questions
i.
Applicants must submit answers to each of the background questions.
ii.
Question 1:
(1)
If you answer “yes” to this question, you must complete Section III (b) [make
additional copies as necessary] of the application and provide a copy of the arrest
report, copies of the disposition or final order(s), and documentation proving all
sanctions have been served and satisfied. You must supply this documentation
for each occurrence. If you are unable to supply this documentation, a certified
statement from the Clerk of Court for the relevant jurisdiction stating the status of
records is required.
(2)
If you are still on probation, you must supply a letter from your probation officer, on
official letterhead, stating the status of your probation.
iii.
Question 2:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and provide a copy of the judgment
or decree. You must also supply documentation proving all sanctions have been
served and satisfied, or if not, stating the current status of any proceedings.
iv.
Question 3:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and supply copies of
documentation explaining the denial or pending action.
v.
Question 4:
(1)
If you answer “yes” to this question, you must complete Section III (c) [make
additional copies as necessary] of the application and supply copies of the order(s)
showing the disciplinary action taken against the license, or documentation showing
the status of the pending action.
d. Section IV – Explanation of Illness or Economic Hardship
i.
For applicants applying for reinstatement of a null and void license, provide a detailed
explanation of illness or economic hardship that prevented renewal. Attach any
documents you wish to provide to support your claim of hardship.
e. Section V- Affirmation by Written Declaration
i.
Please read and sign the affirmation by written declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
DBPR AA 4101- Application for Licensure as an Athlete Agent
Incorporated by Rule: 61-35.004
Effective: 2014 October
3 of 7
State of Florida
Department of Business and Professional Regulation
Division of Professions: Athlete Agents
Application for Licensure as an Athlete Agent
Form # DBPR AA-4101
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
For additional information see the Instructions at the beginning of this application.
Section I – Application Type
CHECK ONE OF THE APPLICATION TYPES
Athlete Agent Initial License [6001/1030]
Athlete Agent Reinstatement from Null and Void [6001/1033] Previous License No.:___________
Section II – Applicant Information
APPLICANT INFORMATION
Social Security Number*
FULL LEGAL NAME
Last/Surname
First
Middle
Suffix
Birth Date (MM/DD/YYYY)
Gender
/
/
 Male  Female
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
CONTACT INFORMATION
Primary Phone Number
Primary E-Mail Address
RESIDENCE ADDRESS (IF DIFFERENT THAN MAILING ADDRESS)
Street Address
City
State
Zip Code (+4 optional)
County (if Florida address)
Country
ADDITIONAL CONTACT INFORMATION (OPTIONAL)
Alternate Phone Number
Fax Number
Alternate E-Mail Address
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited
by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation
pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1),
Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be
used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
DBPR AA 4101- Application for Licensure as an Athlete Agent
Incorporated by Rule: 61-35.004
Effective: 2014 October
4 of 7
Section II – Applicant Information – continued
CURRENT/PRIOR LICENSE INFORMATION
If you currently hold or have previously held a business or professional license/registration in Florida or
elsewhere, please list each one below (attach additional copies of this page as necessary):
Date (From)
Date (To)
1. License/Registration Type
State
/
/
/
/
License Number
Name Used
Date (From)
Date (To)
2. License/Registration Type
State
/
/
/
/
License Number
Name Used
Date (From)
Date (To)
3. License/Registration Type
State
/
/
/
/
License Number
Name Used
PRIOR NAME INFORMATION
Have you used, been known as, or are currently known by another name (e.g., maiden name or
nickname) or alias other than the name signed to the application? 
Yes
No
If your answer is yes, state name or names used below:
Last/Surname
First
Middle
Suffix
Last/Surname
First
Middle
Suffix
Last/Surname
First
Middle
Suffix
DBPR AA 4101- Application for Licensure as an Athlete Agent
Incorporated by Rule: 61-35.004
Effective: 2014 October
5 of 7
Section III – Background Questions
BACKGROUND QUESTIONS
1.
 Yes
 No
Have you ever been convicted or found guilty of, or entered a plea of nolo
(If yes, please
contendere or guilty to, regardless of adjudication, a crime in any
complete
jurisdiction, or are you currently under criminal investigation? This
Section III (b))
question applies to any criminal violation of the laws of any municipality,
county, state or nation, including felony, misdemeanor and traffic offenses
(but not parking, speeding, inspection, or traffic signal violations), without
regard to whether you were placed on probation, had adjudication
withheld, were paroled, or pardoned. If you intend to answer “NO”
because you believe those records have been expunged or sealed by
court order pursuant to Section 943.0585 or 943.059, Florida Statutes, or
applicable law of another state, you are responsible for verifying the
expungement or sealing prior to answering "NO." YOUR ANSWER TO
THIS QUESTION MAY BE CHECKED AGAINST LOCAL, STATE AND
FEDERAL RECORDS. FAILURE TO ANSWER THIS QUESTION
ACCURATELY MAY RESULT IN THE DENIAL OR REVOCATION OF
YOUR LICENSE. IF YOU DO NOT FULLY UNDERSTAND THIS
QUESTION, CONSULT WITH AN ATTORNEY OR CONTACT THE
DEPARTMENT.
2.
 Yes
 No
Has any judgment or decree of a court been entered against you in this or
(If yes, please
any other state, province, district, territory, possession or nation, related
complete
to the practice or profession for which you are applying, or is there any
Section III (c))
such case or investigation pending?
3.
 Yes
 No
Have you ever had an application for registration, certification, or
(If yes, please
licensure in Florida or in any other jurisdiction denied, or is there now
complete
pending a proceeding or investigation to deny such an application?
Section III (c))
4.
 Yes
 No
Has any license, registration, or permit to practice any regulated
(If yes, please
profession, occupation, vocation, or business been revoked, annulled,
complete
suspended, relinquished, surrendered, or otherwise disciplined in Florida
Section III (c))
or in any other jurisdiction, or is any such proceeding or investigation now
pending?
If you answered “YES” to any question in questions 1-4 above, please refer to Section 2(b) of Instructions
for detailed instructions for providing complete explanations, including requirements for submitting
supporting legal documents. Please complete Section III (b) for your response to question 1, and
complete Section III (c) for your response to questions 2 through 4. If you have more than two offenses
to document in Section III (b), or more than one offense to document in Section III(c), attach additional
pages as necessary.
Section III (b) – Explanation(s) for Background Question 1
EXPLANATION
Offense
County
State
Penalty/Disposition
Date of Offense (MM/DD/YYYY)
Have all sanctions been satisfied?
/
/
 Yes  No
Description
DBPR AA 4101- Application for Licensure as an Athlete Agent
Incorporated by Rule: 61-35.004
Effective: 2014 October
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