Safa Player Agent Application Form – Fill Out and Use This PDF

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	:	Telephone No.	(011) 494 3522
JOHANNESBURG
2000
Republic of South Africa	:	Facsimile No.	(011) 494 3013

South African Football Association

Personal History Disclosure Application Form for a Player’s Agent Licence

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” (for “Not Applicable”) 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 the South African Football Association (“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 I 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

South African Football Association

Personal History Disclosure Application Form for a Player’s Agent Licence

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

First

Middle

Surname

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:

South African Football Association

Personal History Disclosure Application Form for a Player’s Agent Licence

Represented From:		To:
(C) Name:		Sports
		Code:
Address:		City:
Represented From:		To:
(D) Name:		Sports
		Code:
Address:		City:

Represented From:

To:

14.TAX INFORMATION

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

14.2If yes, attach certified true and legible copies of all the pages and supporting schedules of your tax return as well as the corresponding tax assessment and attachment or tax clearance certificate or the equivalent from the country of origin.

Tax reference		Tax authority
number:		location:

South African Football Association

Personal History Disclosure Application Form for a Player’s Agent Licence

Credit card accounts

Electricity

Entertainment

Food and liquor

Insurance premiums / savings

Maintenance of property

Medical expenses not covered by medical aid / Own medical aid

Motor vehicle running expenses

Repayment of borrowings

Telephone

Travelling

Water

Other (specify)

TOTAL EXPENDITURE (B)

NET INCOME / (DEFLICT) (A – B)

19.STATEMENT OF ASSETS AND LIABILITIES

DATE OF STATEMENT: _______________/_________________________/______________

List the values of all assets, both tangible and intangible, in the appropriate spaces below. Enter only Rand amounts as on the date of this statement. The statement date must be as recent as possible, but within the directly preceding three months of the date of this application.

Should you find it necessary, additional information about a listed asset must be described fully in an attached schedule, numbered appropriately, as indicated. Provide either current actual values or current market values as appropriate.

ALL AMOUNTS MUST BE IN SOUTH AFRICAN RANDS.

South African Football Association

Personal History Disclosure Application Form for a Player’s Agent Licence

INDICATE THE APPLICABLE EXCHANGE RATE AND DATE WHEN FOREIGN CURRENCIES WHERE CONVERTED TO SOUTH AFRICAN RAND.

19.1Assets

Assets	Applicant	Spouse + minor	TOTAL
		children

Accounts / monies receivable / tax overpaid

Bank Accounts

Cash on hand (on person, in safe etc.)

Credit card accounts in credit

Household and personal effects

Listed investments (shares and bonds)

Non-listed investments

Property

Surrender value of insurance policies

Unit trusts

Vehicles, planes, boats etc.

TOTAL ASSETS (A)

19.2 Liabilities

Liabilities	Applicant	Spouse + minor	TOTAL
		children
Bank overdraft outstanding
Bonds / mortgages payable
Debit credit card accounts
Hire purchase accounts
payable
Loans payable (secured or