Category C Application

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Declaration

Full Name (Required)

First Last

I, the applicant named above, hereby apply for certification under the PHPA Certified Agent Program pursuant to the PHPA Regulations Governing Agent Certification (the “Regulations”), and confirm that I currently represent one or more elite amateur, drafted, unsigned, NCAA, U SPORTS, CHL, USHL, European professional, or other elite hockey Player(s).

Prior to completing and signing this Application, I have received and read the PHPA Regulations Governing Agent Certification (the “Regulations”).

By submitting this Application, I voluntarily agree to comply with and be bound by the Regulations, as amended from time to time, which are incorporated into this Application by reference.

I understand that absolute and complete candor is required. Any false, misleading or incomplete statement in an answer on this Application can result in denial, suspension, revocation, or other disciplinary action affecting my certification under the PHPA Certified Agent Program, in accordance with the Regulations.

I understand that this Application and the answers I have provided are designed to benefit the PHPA and its Members, both present and future, by helping to ensure qualified representation. I unconditionally agree that the information contained herein can be maintained and used by the PHPA in performing its functions and can be provided by the PHPA to individual players, including future players.

If granted certification under the PHPA Certified Agent Program, I shall save and hold harmless the PHPA, its officers, employees, committee members, and representatives from any liability arising from my own acts or omissions while providing services to any Player.

If my Application for Certification is denied, or if my certification is subsequently suspended or revoked in accordance with the Regulations, I acknowledge that my rights and remedies shall be limited to those provided for in the Regulations.

In consideration of the PHPA reviewing this Application, I acknowledge that this Application, together with the Regulations, shall constitute an agreement between the PHPA and me with respect to my Application for Certification and, if approved, my continued certification.

Prior certification (check one) (Required)

I have been previously certified by the PHPA or the NHLPA

I have not been previously certified by the PHPA or the NHLPA

ALL QUESTIONS MUST BE ANSWERED COMPLETELY.

1. General

Your full name was collected on the previous page.

Home Address (Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone (Required)

Date of Birth (Required)

mm/dd/yyyy

Social Insurance Number (Canada) or Social Security Number (U.S.) (Required)

Enter the 9-digit number. If you have neither, enter N/A. This answer is encrypted and can only be read by PHPA staff who hold a key.

Name of Agency (Required)

Business Address (Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone (Required)

E-mail (Required)

Website

2. Have you ever been known by any other name or surname? If so, state all names used and when used.

If you are a married woman, please state your maiden name.

3. Law or Graduate School(s) Attended

School

City, State/Province

Degree

Date Awarded

School (2)

City, State/Province (2)

Degree (2)

Date Awarded (2)

4. Colleges or Universities Attended

School

City, State/Province

Degree

Date Awarded

School (2)

City, State/Province (2)

Degree (2)

Date Awarded (2)

5. High School Attended

School

City, State/Province

Degree

Date Awarded

School (2)

City, State/Province (2)

Degree (2)

Date Awarded (2)

Employment Status & Personal Affiliations

6. State the name, nature and location of each business, firm or organization with which you’re presently affiliated. (Required)

7. What is the nature of your affiliation to each business, firm or organization referred to in question 6 above (i.e. employee, officer, director)? (Required)

8. For the past 10 (ten) years state the nature and location of each business, firm or organization with which you were formerly affiliated, and provide the relevant dates of each affiliation. (Required)

9. For each business, firm or organization with which you are presently affiliated, identify all offices (including address and telephone number) at which the business of providing services to professional athletes is conducted. If there is more than one location, designate the principal office. (Required)

10. For each business, firm or organization with which you are presently affiliated, state whether it is a sole proprietorship, corporation, partnership, or other entity (specify). (Required)

11. For each such business, firm or organization with which you are presently affiliated: (a): if it is a partnership, state the name of each partner; (b): if it is a corporation, state the name of each officer, member of the Board of Directors and shareholder. (Required)

12. For each of the individuals referred to in question 11, identify those partners, officers or members of the Board of Directors, or shareholders who perform work for professional athletes. (Required)

13. Identify each person, not named in question 12 above, who: (a) has any ownership interest in each business, firm or organization with which you are presently affiliated; (b) has wholly or partially financed each business, firm or organization with which you are presently affiliated; or (c) directly or indirectly exercises or has the power to exercise a controlling influence over the management of each business, firm or organization with which you are presently affiliated. (Required)

14. Describe the ownership interest, amount of financing, and/or basis of controlling influence or authority for each person listed in question 13 above. If the business, firm or organization listed in this response is a partnership, list each partner, if a corporation, list each officer, member of the Board of Directors and shareholder. (Required)

15. With respect to each business, firm or organization with which you are presently affiliated list all persons engaged in the representation of professional athlete(s) and his/her area(s) of speciality, if any. (Required)

Current Player Representation

16. Please list below (or attach a separate list) the names of Elite Amateur Players whom you currently represent with the date on which your representation commenced. (Required)

One Player per line, in the format: Player Name — date representation commenced (mm/dd/yyyy). You may also attach a separate list below.

Attach a separate list of Players (optional)

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 10.

17. For each Player identified in Question 16, please attach documentation to your submission establishing your current player-agent relationship, such as a representation agreement or engagement letter. (Required)

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 10.

Lawyers and Law Graduates

Complete this section only if you are a lawyer or a law graduate.

Are you a lawyer or a law graduate? (Required)

Yes

No

27. Name all jurisdictions and courts in which you are admitted to practice law. Include dates of admission, attorney registration number, and status (e.g. active, inactive, non-resident, suspended, etc.) (If you are admitted in the State of New York, specify which Departments) (Required)

One per line: Jurisdiction – Date of Court Admission – Attorney Registration # – Status.

28. Have you ever been denied admission to the practice of law in any jurisdiction (other than for failure of the bar examination) or been denied access to the bar exam of any jurisdiction? (Required)

Yes

No

If so, provide a detailed explanation of the reason you were denied and the name of the jurisdiction in which you were denied. (Required)

29. Have you ever had your fitness to practice law questioned through an informal interview, formal hearing, or through any other means? (Required)

Yes

No

If so, provide a detailed explanation of each instance including the reason(s) for inquiry, nature of questioning and final outcome. (Required)

30. Name all jurisdictions to which you have applied for a license to practice law but to which you have not been admitted to practice law. Include any jurisdictions from which you have withdrawn an application or in which an application is currently pending. Indicate whether the application was on-motion or exam, date filed or date of exam (if applicable), result (e.g. pass, fail, application pending, withdrawn) and if not yet admitted, anticipated date of admission. (Required)

One per line: Jurisdiction – Application Type – Date Filed – Result – Anticipated Admission Date (if applicable). Enter "None" if this does not apply.

31. Has your license to practice law in each of the locations specified above ever been limited, restricted, suspended, or revoked (including periods of inactive or non-resident status) since the date of your admission? (Required)

Yes

No

If so, provide dates during which it has been limited, the nature of the limitation, the facts, and the name and address of the person or authority in possession of the records relating to the matter. (Required)

32. Provide the name, location and dates of admission of each bar association of which you are or have been a member. (Required)

Amateur / Developmental Player Representation

51. Please describe your intended role with amateur or developmental players as they transition into professional hockey. Include whether you intend to: continue representing players at the professional level, transition players to another certified representative, act solely in an advisory capacity, or provide other support or consulting services. (Required)

52. Please describe the methods by which you identify, recruit, or establish relationships with prospective hockey players and their families. Include any involvement with: Scouting services, skill development programs, billet or family advisor programs, recruiting showcases or events, educational advising; or third-party marketing or consulting organizations. (Required)

53. Have you ever entered into any agreement, arrangement, or understanding with an amateur player that may have affected the player's NCAA eligibility or amateur status? (Required)

Yes

No

If yes, please provide full details. (Required)

54. Do you currently employ, retain, or work with any scouts, recruiters, skill coaches, advisors, or other individuals involved in player recruitment or development? (Required)

Yes

No

If yes, please identify those individuals and describe their role within your business operations. (Required)

55. Please describe how you intend to educate players and their families regarding: Professional contract structures, applicable league rules and regulations, financial planning and considerations, NCAA eligibility implications, and the transition from amateur to professional hockey. (Required)

56. Have you previously negotiated, advised on, or facilitated any agreements involving: the NHL, the AHL, the ECHL, European professional leagues, or NIL or other commercial opportunities? (Required)

Yes

No

If yes, please provide examples and describe your role in such matters. (Required)

57. Please explain why you are seeking PHPA Certified Agent status and how certification aligns with your long-term professional and business objectives. (Required)

58. References

Please list below the names, addresses and telephone numbers of at least five (5) persons, not related to you, who have known you for at least the last five (5) years and who can attest to your character. (Names of officers, player representatives, or staff members of the PHPA may not be used.)

Reference 1 (Required)