NIL Disclosure Form

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Email address *

Name: *

Cell Phone: *

Institution: *

Sport: *

If you selected other in the question above please specify what activity you will participate in that you were be compensated for

List all involved parties for the activies in which you were compensated, including any agent representation you may be involved with:

Names *

Business/Company: *

Role: *

Phone/Email: *

What are the terms for the agreement? *

What is the start date/time of the agreement? *

What compensation will take place as result of your participation *

Will (or were) any institutional logos or trademarks be used for the activity *

Yes No

If yes, did you receive institutional approval

Yes No

Will (or were) institutional facilities be used for the activity *

Yes No

If yes, did you receive institutional approval

Yes No

Did anyone from your institution assist you with this arrangement *

Yes No

If yes, who?

If yes, describe their involvement:

Please provide more detail about the activity checked above: *

My signature below affirms that I have disclosed complete and accurate information regarding my compensated NIL activity/activites stated above. I further affirm that I have followed all pertinent CCCAA Bylaws and that it is my responsibility to understand if/how this compensation will impact my fnancial aid or income tax.

Name: *

Date *

* required field