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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