SAFA Agent Registration Form

South African Football Association
Personal History Disclosure Application Form for a Player’s Agent Licence

APPLICATION FOR A PLAYERS’ AGENT LICENCE

Full name of applicant:

Date of completion of form:

SAFA Licence:

All correspondence to be addressed to:

The Chief Executive Officer

P O Box 910
JOHANNESBURG
2000
Republic of South Africa

Telephone No. (011) 494 3522

Facsimile No. (011) 494 3013

APPLICATION INSTRUCTIONS

1. Read these instructions and every question carefully before answering and follow any specific instruction which may be given in respect of certain questions.

2. Answer every question in full. If you fail to answer any question or given incomplete answers or fail to submit all the additional information required, your application may be rejected. NB if you comply with question 14.2 then you need not complete questions 18, 19, 20 and 21.

3. If a question does not apply to you, write “N/A” in the space provided for the answer. If there is nothing to disclose about a particular question, write “None” in the space provided for the answer. If an alteration is made to an answer, sign in full next to the alteration.

4. All answers on this form, except signatures, must be typed or neatly printed in black ink. On completion, each page of this form must be signed in full in the space provided at the bottom of each page.

5. This application form must be completed by the person applying for the Players’ Agent’s Licence to be issued by SAFA. Return the completed form to the Chief Executive Officer of SAFA, P O Box 910, JOHANNESBURG 2000, Republic of South Africa or, if by hand, to the SAFA House, 76 Nasrec Road, NASREC, JOHANNESBURG, Republic of South Africa.

6. The original completed application form and all the additional required information plus two copies of all pages must be submitted to the Board.

7. If you need additional space to answer any question, please use additional pages, but be sure to indicate the number(s) of the question(s) you are answering on these additional pages and clearly cross reference the additional information with the relevant questions.

8. The original application form must be accompanied with a photograph of the applicant taken not more than one month before the submission of this application form.

9. If there is not enough space on the schedules for the financial information, additional information of the applicant, the applicant’s spouse or children must be given on additional pages in the same format as those of the relevant schedules pertaining to this application form.

10. If any details of the applicant, which are reflected in this application form, change before a licence has been issued SAFA must immediately be notified in writing.

11. All dates must be in the format: DAY / MONTH / YEAR

(Attach certified true copies of all pages of ID document if a new document was issued during the past twelve months)

1. APPLICANT

Name

ID No.

Current Home Address

Suburb Postal Code

Town / City Country

Telephone No. (home) Telefax No.

Cell Phone No. E-mail Address

Current Business Address

Suburb Postal Code

Town / City Country

Telephone No. (work) Telefax No.

2. CHANGES IN FAMILY DETAILS DURING PAST TWELVE MONTHS

All applicants must disclose any changes in his/her family information in full. If a relative passed away during the past twelve months, give all the information that is requested, including his or her last place or residence and the date of his or her death. If you are co-habiting, engaged or to be married or are contemplating marriage in the near future, give full particulars about this, indicating clearly the nature of the relationship being planned.

SPOUSE / COMMON LAW WIFE / PARTNER

Name

Street Address

Suburb Postal Code

Town / City Country

Date of Birth Place of Birth

Date of Marriage / Commencement of Current relationship ID Number

Current / Last Employer

Address of Employer

CHILD / STEP-CHILD

Name

Street Address

Suburb Postal Code

Town / City Country

Date of Birth Place of Birth

ID Number Current / Last Employer

Address of Employer

3. CURRENT EMPLOYMENT INFORMATION

Provide the required information with respect to your current employment below:

Date (From - To)

Name, Address, Telephone & Fax No. of Employer

Job Description & Job Title

Name of Supervisor

Promotion(s) during the past 12 months

4. DISCIPLINARY ACTIONS

Have you been subjected to any disciplinary action / investigation in connection with your employment during the past twelve months? Yes No

If “No”, provide a certificate from your employer confirming such. If “Yes”, provide all documentation relating to such disciplinary action/investigation.

5. MOTOR VEHICLE INFORMATION

Complete the following table in respect of all vehicles registered in your name or the name(s) of your spouse or the persons residing with you during the past twelve months. Include all vehicles (cars, trucks, motorcycles, recreational vehicles), aeroplanes, boats:

6. CIVIL PROCEEDINGS

6.1 Have you or your spouse/partner been party to personal litigation during the past twelve months? Yes No

If “Yes”, give details in the table below:

6.2 Have any civil judgements against yourself, spouse or partner been abandoned or rescinded during the past twelve months? Yes No

If “Yes”, give details below:

7. SUMMONSES and SUBPOENAS

7.1 Have you been summonsed, subpoenaed, requested or otherwise required to appear or to testify before any municipal, provincial, country or national court, agency, committee, grand jury or investigative regulatory body, other than in response to a traffic summons or has your spouse or partner in any business entity, in which you hold or have held an ownership interest been so summonsed, subpoenaed, requested or otherwise required to appear or to testify during the past twelve months? Yes No

8. INVESTIGATIONS

Have you been the subject of an investigation conducted by a government investigative agency for any reason or has your spouse or partner or business entity in which you hold or have held an ownership interest, been the subject of such an investigation during the past twelve months? Yes No

9. CRIMINAL OFFENCES

Have you been arrested, indicted for, or convicted of a criminal offence or has any member of your immediate family been so arrested, indicted, charged or convicted during the past twelve months? If so, list all cases, irrespective of the outcome. Yes No

10. CRIMINAL PROCEEDINGS

Have you been called as a witness in any criminal proceedings, or has any member of your family been involved in such criminal proceedings during the past twelve months. Yes No

11. INSURANCE

11.1 Have you sustained either a personal or business loss in respect of which an insurance payment of more than R100 000 was paid to you during the past twelve months? Yes No

11.2 Have you ceded an insurance policy during the past twelve months? Yes No

12. POSITIONS HELD IN FOOTBALL

12.1 Do you hold any positions in any of the following organizations?

12.1.1 FIFA Yes No

12.1.2 A Confederation e.g. SAFA Yes No

12.1.3 A League e.g. NSL or PSL Yes No

12.1.4 A Region or Province of SAFA Yes No

12.1.5 A District of SAFA Yes No

12.1.6 An Associate member of SAFA Yes No

12.1.7 A Club Yes No

12.1.8 FIFA Yes No

12.2 Do you hold any positions in any of the following organizations?

12.2.1 Do you hold a position with any organization connected with these institutions? Yes No

12.2.2 If the answer to 12.2 is yes, please provide details.

13. EXPERIENCE AS AN AGENT

13.1 List the names, addresses telephone numbers of each person for whom you have acted as an agent. Include the beginning and ending dates of your representation and include which sports code. Please attach additional sheet(s) if necessary.

14. TAX INFORMATION

14.1 Have you filed your income tax returns during the past twelve months? Yes No

Tax reference number: Tax authority location:

14.3 If no, give an explanation below and provide a personal income statement and balance sheet for the past twelve months ending:

14.4 Have you been granted an extension to render your income tax return during the past twelve months? Yes No

14.5 Have you been delinquent in submitting your tax return or paying your financial obligation to any tax authority during the past twelve months? Yes No

15. ATTACHMENTS

Have your wages, salary, earnings or other income been garnished or attached or any similar action taken during the past twelve months? Yes No

16. DIRECTORSHIPS

List all directorships currently held (attach separate list if necessary).

17. BANK ACCOUNTS

Have you or your spouse opened or closed any bank account which was issued in your name, your spouse’s name or in the name of any entity which you or your spouse controlled, during the past twelve months? Yes No

18. MONTHLY INCOME AND EXPENDITURE STATEMENT

Provide details below for your current monthly income and expenditure for the past twelve months. All amounts must be in South African Rand. Indicate the applicable exchange rate and date when a foreign currency is converted to South African Rand.

19. STATEMENT OF ASSETS AND LIABILITIES

DATE OF STATEMENT:

19.1 Assets

19.2 Liabilities

NET WORTH (A – B)

20. OFF-BALANCE SHEET ASSETS

List all assets, except fixed property, used but not owned by the applicant or spouse below e.g. vehicles, planes, boats, etc. as well as the market value of these assets.

21. CONTINGENT LIABILITIES

List all contingent liabilities (e.g. guarantees) as well as the amounts involved.