INDIVIDUAL REFEREE INFORMATION FORM



APPLICATION

for a FIBA Players' Agents Licence

Rio de Janeiro, Brazil

15th April 2011

in accordance with the FIBA

Internal Regulations governing Players Agents

I. Personal Data

|Agency/Company |_____________________________________________________________ |

|Family (last) Name |_____________________________________________________________ |

|First (given) Name |_____________________________________________________________ |

|( Company Address |Street ________________________________________________________ |

|( Private Address |Zip Code ______________ City _________________________________ |

| |Country _____________________________________________________ |

|Telephone: |Country code________City code_________Number___________________ |

|Mobile phone: |Country code________City code_________Number___________________ |

|Fax: |Country code________City code_________Number___________________ |

|E-mail: |other than “@ ” _________________________________________ |

|Date of Birth: |Day_________________Month_____________Year___________________ |

|Place of Birth: |_____________________________________________________________ |

|Nationality: |_____________________________________________________________ |

II. The Following Documents are attached to this Application

|( |Certificate of No Conviction (issued by the State Government Authorities & not older than 6 months) |

|( |One passport-size photograph |

|( |A valid licence for national transfers (only if provided by your National Federation) |

III. Declarations

|I hereby declare that I do not hold a position with FIBA, a Zone Commission, a National Federation, a Club or any Organisation connected|

|with such entities such as leagues or Players Associations. I also declare that I hold no position with any other international or |

|national basketball organisation. |

|I recognise that I will be invited by FIBA for a personal interview and a test and that I will have to pay a fee of $ 200. - for the |

|test. |

|I recognise that I will have to pay an annual fee in accordance with the FIBA Agent Regulations as long as I hold a FIBA Players' Agent |

|Licence. |

|I intend to participate to the personal interview and test taking place in Rio de Janeiro, Brazil at the “Windsor Atlantica Hotel in |

|Copacabana” on the Friday 15th April 2011 at 10:30 a.m |

|I recognise that in accordance with the FIBA Agent Regulations I will have to attend a refresher seminar organised by FIBA every two |

|years to verify that the requirements for the issuing of the licence are still met. |

|I recognise that the FIBA Internal Regulations, in particular the FIBA Agents Regulations as amended from time to time are applicable to|

|my relationship with FIBA as a Players' Agent and I further recognise that I am subject to disciplinary sanctions by FIBA in case of |

|breach of any of these regulations. |

|I recognise that in accordance with the FIBA Agent Regulations in the event that the national federation of my home country enacts |

|regulations governing the activities of agents, I will be obliged to prove to FIBA that I am the holder of a valid licence issued by |

|that federation. |

Date: ______________________________

Place: ______________________________ Signature: _____________________________

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PUR-APPLICATION FORM - MAY 2010.doc/ IT

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