Name, Image, and Likeness Agreement Disclosure Form

Email address *

First name *

Last name *

Cell Phone Number *

Today's Date *

Date Picker

Sport *

Describe the NIL activity that you will be doing. *

What are you being asked to do?

What are the terms of the potential agreement? *

Start Date of NIL Activity *

Date Picker

End Date of NIL Activity *

Date Picker

List everyone involved in the agreement, and their contact information *

Name of Business and/or Individual, Title, Role and Email

I affirm to the best of my knowledge: I have confirmed that this activity is consistent with state law/executive action and institutional policy. I understand that I am responsible for determining whether this activity is consistent with state law executive action, if applicable, and that the NCAA will not interpret state law/executive action and/or institutional policy. ? To the extent required by state law/executive action and/or institutional policy, I have provided complete and accurate information regarding any and all activities involving use of my name, image and likeness, including compensation arrangements and information about individuals and entities involved in the activity. ? Compensation was/is related to actual use of my name, image and likeness and was/is not contingent on enrollment at a particular institution or a substitute for pay for athletics performance. *

Yes No

I acknowledge that my institution, or a designee of my institution, may review the accuracy of this information, and I consent to any investigation, review, or audit. I acknowledge that inaccurate or incomplete disclosure, or failure to cooperate could support a reasonable conclusion that compensation I received constituted an inducement to attend or remain enrolled at a specific school, a substitute for pay for athletics performance or participation, or an otherwise illegitimate source of compensation for use of my name, image, and likeness. *

Yes No

I understand typing my name into this document in the spaces below is the equivalent of a signature. *

Yes No

Name *

Today's Date *

Date Picker

Date of Birth *

Date Picker

Home Address *

Street, City, State and Zip Code

* required field